HEArTH  SCIENCES  STANW 


HX64101282 
>101  .G91  1921     The  blood  supply  t 


ap  iot 


n-1 


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THE  BLOOD  SUPPLY 
TO  THE  HEART 


THE  BLOOD  SUPPLY 
TO  THE  HEART 

IN  ITS  ANATOMICAL  AND  CLINICAL  ASPECTS 


BY 

LOUIS  GROSS,  M.D..C.M. 

Douglas  Fellow  in  Pathology,  McGill  University,  and  Research  Associate, 
Royal  Victoria  Hospital,  Montreal 

With  an  Introduction  by  HORST  OERTEL 

Strathcona  Professor  of  Pathology,  McGill  University,  Montreal 


WITH  TWENTY-NINE  FULL  PAGE  PLATES 
AND   SIX  TEXT  ILLUSTRATIONS 


PAUL  B.  HOEBER 
NEW  YORK 


Copyright,   192  i 
Bv  PAUL  B.  HOEBER 


Printed  in  the  United  States  of  America 


TO  MY  ALMA  MATER 

AND 

ALL  THOSE  FROM  WHOM  SHE  DREW 

HER  GREATNESS  AND  NOBILITY 

THIS  BOOK  IS  DEDICATED 

ON  THE  OCCASION  OF 

THE  MC  GILL  UNIVERSITY  CENTENNIAL 

OCTOBER,    NINETEEN    HUNDRED    AND    TWENTY-ONE 


INTRODUCTION 

This  monograph  on  the  blood  supply  to  the  heart  in  its 
anatomical  and  clinical  aspects  is  the  outcome  of  investiga- 
tions which  Dr.  Gross  commenced  several  years  ago  in  the 
laboratories  of  the  Royal  Victoria  Hospital  and  of  McGill 
University.  They  formed  originally  part  of  a  general  study 
dealing  with  structural  evolution  of  organs  in  the  various  age 
periods  in  its  relation  to  normal  function  and  disease.1 

It  soon  became  apparent  to  me  that  in  these  researches 
Dr.  Gross  had,  with  rare  industry  and  ingenuity,  gone  far 
beyond  the  original  questions  and  that  the  results  of  his  work 
touch  upon  a  larger  number  of  problems  which  are  not  only 
of  anatomical,  but  also  of  great  clinical  interest  and  impor- 
tance. The  extent  of  the  work  and  the  accumulated  material 
and  illustrations  had  also  gone  far  beyond  the  original  scope  of 
a  paper  and  it  was  therefore  considered  advisable  to  publish 
it  in  monograph  form.  This  allowed  a  further  extension  and 
inclusion  of  a  thorough  critical  review,  and  incorporation 
of  previous  literature — by  itself  a  useful  undertaking.  The 
work,  therefore,  places  before  us: 

First:  A  complete  description  of  the  arterial  and  venous 
blood  supply  to  the  normal  heart  with  a  statistical  study  of  its 
variations. 

Second:  The  blood  supply  to  the  neuromuscular  system  of 
His  and  its  pathological  and  clinical  significance. 

■See  Ocrtel,  Post-Natal  Development  and  Pathological  Organ    Reconstruction  in 
Relation  to  Function  and  Disease,  Am.  J.  M.  Sc,  May,   1921,  p.  694. 


viii  INTRODUCTION 

Third:  A  new  standpoint  in  the  discussion  of  the  anatomical 
factors  concerning  the  etiology  and  development  of  valvular 
endocarditis. 

Fourth:  A  newer  view  on  the  physiological  course  and 
character  of  the  cardiac  circulation  in  the  various  age  periods 
and  their  relation  to  physiological  and  pathological  functions. 

The  monograph  contains,  so  far  as  I  know,  a  complete 
presentation  of  the  subject  to  date  and  possesses  for  anatomist, 
physiologist,  pathologist  and  clinician  alike  an  unusual  com- 
bination of  interest  and  usefulness. 

Mr.  Hoeber's  rare  good  will  to  publish  the  work  is  an 
illustration  of  his  unselfish,  scientific  spirit. 

Horst  Oertel. 

McGill  University  ;ind  The  Roy;il  Victoria 

Hospital,  Laboratories  of  Pathology. 

Montreal,  July,  1921. 


PREFACE 

The  author  was  primarily  interested  in  the  study  of  the 
circulation  of  the  heart  in  its  relation  to  age  periods  and 
in  its  pathological  variations.  For  a  lull  appreciation  of  the 
changes  in  the  cardiac  circulatory  architecture  under  these 
conditions,  it  was  found  advisable  to  make  a  thorough  study 
of  the  normal. 

A  review  oi  the  literature  proved  inadequate  to  allow  an 
intelligent  grasp  oi  the  subject  and  only  served  to  perplex  by 
its  chaotic  state.  With  much  difficulty  it  was  attempted  to 
coordinate  the  various  views,  and  there  remained  many  points 
of  dispute  and  a  large  number  ol  problems.  The  author  con- 
sequently made  a  personal  study  of  the  circulatory  struc- 
ture in  the  normal  heart  in  order  to  investigate  as  many 
ol  the  moot  points  as  possible  and  also  to  acquire  a  standard 
lor  comparison  with  the  results  ol  future  investigations  into 
pathological  conditions. 

hi  the  course  ol  this  research  a  technique  was  developed, 
which,  it  is  believed,  is  eminently  suited  lor  investigations  of 
this  nature.  Main  of  the  disputed  points  have  been,  it  is 
hoped,  settled  and  a  number  of  new  and  interesting  fields  for 
speculation,  opened.  Chief  among  the  latter  is  the  question 
ol  tin-  effect  of  age  on  the  course,  character  and  physiologj 
ol  the  cardiac  circulation.  It  was  found  that  a  very  charac- 
teristic series  ol  changes  takes  place  as  age  progresses.  This 
appears,   In    itself,  an   interesting  contribution  to  the  clinical 


x  PREFACE 

appreciation  of  the  physiology  and  pathology  of  senile  heart 
and  death. 

The  blood  supply  to  the  neuromuscular  system  was  worked 
out  with  care.  It  was  found  that  the  anatomy  of  the  neuro- 
muscular circulatory  structure  could  be  intelligently  correlated 
with  functional  derangements  such  as  presented  by  classical 
cases  found  in  the  literature. 

Moreover,  much  of  the  reported  experimental  work 
acquired  a  new  meaning.  With  the  results  of  a  series  of  experi- 
ments which  the  author  himself  undertook,  the  anatomical 
factors  which  enter  into  the  production  of  valvular  endocarditis 
have  been  put  in  a  position  which  appears  to  throw  new  light 
upon  the  clinical  and  anatomical  experiences  of  previous 
investigators. 

In  view  of  the  accumulation  of  these  facts  and  the  work 
that  was  required  to  make  a  thorough  search  into  the  litera- 
ture, Professor  Horst  Oertel  suggested  to  present  the  whole 
matter  in  monograph  form.  It  has  consequently  been  decided 
to  present  in  these  pages  a  summary  of  the  state  of  our  know- 
ledge on  this  subject. 

For  convenience  in  handling  the  matter,  it  has  been 
divided  into  eight  chapters.  It  is  true  that  the  divisions 
overlap  somewhat,  but  in  this  way  the  historical  review  oi 
the  various  problems  is  much  more  comprehensively  handled. 

The  general  plan  is  to  give  a  concise  historical  survey  of  the 
matter  dealt  with  in  a  chapter,  indicating  briefly  the  technique 
employed  by  the  various  investigators;  then  to  outline  the 
present  state  of  knowledge  and  finally  to  add  the  author's 
contribution. 

Appended  is  a  bibliography  arranged  in  alphabetical 
form.  As  far  as  possible,  this  was  made  complete.  Unavoidably, 


PREFACE  xi 

some  contributions  must  have  been  left  out,  but  it  is  hoped 
that  the  bibliography  forms  in  itself  a  complete  chain  of  evi- 
dence, reflecting  the  phases  of  thought  through  which  the 
subject  has  passed. 

The  cross  index  should  render  the  book  of  more  ready 
reference  and  increase  its  usefulness. 

The  author  wishes  to  take  this  opportunity  to  thank 
Prof.  Horst  Oertel  for  his  generous  and  sympathetic  advice 
throughout  the  work.  To  Dr.  J.  D.  Morgan,  roentgenologist  of 
the  Royal  Victoria  Hospital,  and  to  Mr.  Black  of  the  United 
Photographic  Store,  Montreal,  he  is  much  indebted  for  the  beau- 
tiful roentgenograms,  plates  and  photographs  which  have  made 
the  work  possible.  To  Mr.  H.  E.  Webster,  Superintendent  of  the 
Royal  Victoria  Hospital,  who  has  kindly  supplied  apparatus 
and  laboratory  facilities,  to  Drs.  Semple,  Pitts,  Waugh  and 
Branch  for  autopsy  material,  and  to  his  wife  for  invaluable 
aid  in  preparing  the  bibliography,  the  author  also  wishes  to 
express  his  appreciation.  Not  the  least  of  these,  he  owes  thanks 
to  Mr.  Paul  B.  Hoeber  for  the  kindly  interest  he  has  taken  in 
publishing  this  work. 

L.  G. 

McGill  University  and  The  Royal  Victoria 

Hospital,  Laboratories  of  Pathology. 

Montreal,  July,  192 1. 


CONTENTS 

CHAPTER  PACK 

I.  Technique i 

II.  The  Blood  Supply  to  i hi  :  Ventricles  and  Auricles.    ...  11 

III.  Variation  in  the  Distribution  of  the  Coronary  Arteries    .  26 

[V.  The  Blood  Supply  to  the  Neuromuscular  Tissue 37 

V.  The  Blood  Supply  to  the  Heart  Valves  and  Its  Relation 

to  the  Inflammations  of  the  Valves 53 

VI.  The  Anastomoses  Between  the  Coronary  Arteries.   ...     77 

VII.  The  Veins  of  the  Heart 93 

VIII.  Age  Period  Changes  in  the  Blood  Supply  to  the  Heart  and 

Their  Pathogenetic  Relations 105 

Bibliography 153 

[ndi  \ [65 


LIST  OF  ILLUSTRATIONS 

FIGURE  PAGE 

i.  Flanged  Glass  Nozzle 4 

2.  Flanged  Metal  Needle 5 

3.  Injection  Apparatus 6 

4.  Roentgenogram  of  the  Blood  Supply  in  the  Average  Heart 13 

5.  Photograph  of  injected  and  cleared  specimen,  showing  the  ulti- 

mate Subendocardial  Distribution  of  the  Coronary  Arteries i- 

6.  Diagram  of  cross  section  through  the  heart  showing  the  regions 

supplied  by  the  Left  and  Right  Coronary  Arteries 24 

7.  Roentgenogram    of    a    typical    variation    in    Coronary    Artery 

Distribution 27 

8.  Photograph  ol  injected  and  cleared  specimen,  showing  the  Blood 

Supply  to  the  Neuromuscular  Tissue  on  the  Right  Side 45 

9.  Photograph  of  injected  specimen,  showing  the  Blood  Supply  to  the 

Aortic  Cusp  of  the  Mitral  Valve  which  is  the  seat  ot  an  Acute 
Endocarditis 59 

10.  Photograph  of  the  Tricuspid  Valve  from  the  same  Heart  as  in 

Fig.  9 61 

11.  Photograph  of  the  Pulmonary  Valve  from  the  same  Heart  as  in 

Fig.  9 63 

12.  Photograph  of  the  Aortic  Valve  from  the  same  Heart  as  in  Fig.  9, 

showing  the  Blood  Supply  to  the  Cusps 65 

13.  Photograph  of  injected  specimen,  showing  the  Blood  Supply  to 

the  Aortic  Leaflet  of  a  Normal  Mitral  Valve 69 

14.  Photograph     of     injected     and     cleared    specimen,    showing   the 

Anastomoses  on  the  Anterior  Surface  of  the  Heart 8~ 

15.  Roentgenogram  of  the  Venous  Distribution  in  the  Average  Heart.    95 

16.  Graph  showing  the  increase  of  Subpericardial  Fatty  Tissue  as  Age 

A<l\  ances 109 

i~.   Graph   showing  the  absolute   Increasing  Weight  of  the  right  and 

left  Ventricles  as  Age  Advances,  and  also  the  relative  increasing 

preponderance  of  left  over  right  side 112 

18.   Roentgenogram  of  the  Blood  Supply  in  the  Average  Heart  at 

Birth 115 

\\ 


xvi  LIST  OF  ILLUSTRATIONS 

FIGURE  PAGE 

19.  Photograph    of    Injected    and    cleared    specimen,    showing    the 

Superficial  Distribution  of  the  Coronary  Arteries  at  Birth 115 

20.  Roentgenograms  of  the  Blood  Supply  in  the  Average  Heart  of  the 

First  Decade  117 

21.  Roentgenograms  of  the  Blood  Supply  in  the  Average  Heart  of  the 

Second  Decade 119 

22.  Roentgenograms  of  the  Blood  Supply  in  the  Average  Heart  of  the 

Third  Decade 121 

23.  Roentgenograms  of  the  Blood  Supply  in  the  Average  Heart  of  the 

Fourth  Decade 123 

24.  Photograph  of  the  Anterior  Surface  of  an  injected  and  cleared 

Heart  of  the  Fourth  Decade,  showing  the  Distribution  of  the 
Arteriae  Telae  Adiposae 125 

25.  Photograph  of  the  Posterior  Surface  of  the  same  Heart  as  in  Fig. 

24,  showing  the  Distribution  of  the  Arteriae  Telae  Adiposae.  .  .    127 

26.  Roentgenograms  of  the  Blood  Supply  in  the  Average  Heart  of  the 

Fifth  Decade 129 

27.  Roentgenograms  of  the  Blood  Supply  in  the  Average  Heart  of  the 

Sixth  Decade 131 

28.  Roentgenograms  of  the  Blood  Supply  in  the  Average  Heart  of  the 

Seventh  Decade 133 

29.  Roentgenograms  of  the  Blood  Supply  in  the  Average  Heart  ot  the 

Eighth  Decade 1 35 

30.  Roentgenogram  of  the  Blood  Supply  in  the  Average  Heart  at  Birth 

and  in  the  Seventh  Decade,  illustrating  the  marked  evolutionary 
changes  which  the  Advancing  Age  Periods  have  produced 139 

31.  Roentgenogram    of  an   injected   heart,  showing  the  results  of  a 

well-marked  and  almost  complete  Arteriosclerotic  Obliteration 

of  the  Right  Coronary  Artery 141 

32.  Photograph  of  injected  and  cleared  specimen,  showing  the  devel- 

opment of  the  Rami  Telae  Adiposae  on  the  right  side  ot  the 
heart,  illustrated  in  Fig.  31 143 

33.  Microphotograph  of  a  section  through  the  Arteriosclerotic  Vessel 

from  the  heart,  illustrated  in  Fig.  31 145 

34.  Photograph  of  injected  and  cleared  specimen,  showing  the  Rami 

Telae  Adiposae  on  the  left  side  of  the  heart,  illustrated  in  Fig.  31 .    146 


Chapter   I 
Technique 

a.  older  methods 

THE  earliest  observations  which  arc  recorded  on  the 
blood  supply  to  the  heart,  date  from  the  middle  of 
the  sixteenth  century.  These  were  made  purely  on  the 
basis  of  dissections.  A  number  of  these  from  Vesalius, 
Fallopius,  Riolanus  and  others  are  found  to  be  just  as  true 
to-day  as  at  the  time  they  were  made. 

Haller,  whose  detailed  account  of  the  coronary  artery 
circulation  was  published  in  i~5_,  has  given  us  a  most  remark- 
able illustration  of  what  excellent  results  can  be  obtained  by 
careful  dissection. 

Obviously,  this  method  had  its  limitations;  conseciuently, 
later  investigators  employed  injections  of  the  blood-vessels 
with  metals,  followed  by  corrosion  of  the  tissues.  Thus,  Ilyrtl 
in  [855  contributed  a  great  deal  to  our  knowledge  of  the  more 
minute  circulation  in  the  heart  as  well  as  in  other  organs.  His 
method  consisted  in  injecting  a  metallic  alloy  of  low  melting 
point  into  the  blood-vessels  and  subsequently  placing  the 
organ  in  a  strong  acid.  After  corrosion  of  the  tissue,  the  metal 
cast  was  carefully  washed  free  from  debris.  This  method  has 
been  repeatedly  employed  by  many  investigators  since  Hyrtl 
and  has  been  brought  to  a  state  of  perfection  by  Nussbaum, 
whose  contribution  to  our  knowledge  of  coronary  artery  cir- 
culation   in    K)ii,   showed    how    such   a    bulky   and   awkward 


2  THE  BLOOD  SUPPLY  TO  THE  HEART 

mass  as  metal  may  nevertheless  be  used  with  very  successful 
results. 

Metal  injections,  however,  were  far  from  the  ideal,  since 
they  could  not  be  forced  into  the  more  minute  channels. 
Moreover,  the  heaviness  of  the  metal  as  well  as  the  necessary 
later  corrosion  introduced  sources  of  difficulties  and  error, 
particularly  for  the  comparative  study  of  finer  and  very  tor- 
tuous vessels,  such  as  are  found  in  chronic  productive 
inflammations  of  parenchymatous  organs,  e.g.,  contracted 
kidney.  Furthermore,  the  organs  must,  often,  subsequently 
be  sectioned  in  order  to  obtain  anything  like  a  comprehensive 
conception  of  the  arrangement  of  the  arterial  tree.  The  diffi- 
culty of  doing  this  without  disturbing  the  metal  cast,  is  appar- 
ent when  we  consider  the  delicate  changes  found  in  pathological 
conditions. 

The  use  of  a  wax  medium  such  as  employed  by  Lexer  in 
1903  and  Hildebrand  in  1907,  instead  of  metal,  is  open  to  the 
same  objections. 

The  introduction  of  roentgenography  stimulated  numerous 
investigators  to  apply  this  method  to  the  study  of  vascular 
architecture.  Hildebrand  credits  Dutto  with  being  the  first 
to  employ  this  method  in  1896. 

The  technique  consisted  in  forcing  pastes  (Opitz,  1897), 
solutions  of  the  salts  of  heavy  metal  suspensions  or,  in  some 
cases,  metallic  mercury  (Glew,  1899)  into  the  blood-vessels 
with  subsequent  roentgenography.  This  was  applied  to  the 
study  of  the  coronary  arteries  by  Freyett  in  1905  and  was 
considerably  perfected  by  Jamin  and  Merkel  in  1907. 

Numerous  investigators  have  employed  this  method,  many 
of  them  modifying  the  medium,  using  different  salts,  colloidal 
silver  (Skinner,  191 2),  pigments  (Miller,  191 8),  etc.,  and  bases 


TECHNIQUE  3 

which  consisted  of  oils  (Stegmann,  1905-6),  paraffin  (Hauch, 
1903),  starch  (Hewson,  1915J,  water  (Smith,  1918),  gelatines, 
etc. 

The  results  of  these  methods  were  extremely  unsatis- 
factory, since  the  pictures  obtained  lacked  the  plasticity  and 
appreciation  of  the  three  dimensions  so  necessary  to  the  full 
understanding  of  circulatory  architecture.  This  fault  was  to  a 
great  extent  eliminated  by  the  introduction  of  the  stereoscopic 
method  of  roentgenography.  Although  many  important  con- 
tributions were  made  in  this  way,  they  were  all  exposed  to  criti- 
cism by  admitting  too  much  possibility  of  artefact  in  the 
technique.  The  results  depended  greatly  on  individual  skill  and 
experience,  and,  as  no  accurate  method  existed  of  estimating  the 
mechanical  force  required  in  the  injection,  i.e.,  pressure  exerted 
on  syringe,  temperature,  viscosity  of  the  medium,  etc.,  com- 
parative studies  were  unreliable  and  practically  useless. 

The  old  method  of  injection  with  pigmented  gelatine  and  of 
subsequent  serial  sections  with  reconstruction  was  of  great 
value.  Its  application,  however,  was  limited  to  the  study  of 
the  microscopic  circulation.  Where  it  was  attempted  to  apply 
it  to  the  reconstruction  of  the  coarser  circulation,  individual 
interpretation  was  the  cause  of  great  diversity  of  opinion  and 
error.  A  modification  of  this  method,  however,  allowed  its 
application  to  the  study  of  the  larger  blood-vessels.  The 
injected  organs  were  dehydrated  and  immersed  in  an  oil  which 
is  able  to  penetrate  the  tissue  thoroughly  and  give  it  a  uniform 
refractive  index  similar  to  the  lluid  in  which  it  is  placed. 
In  tins  way  the  organ  was  rendered  transparent,  so  that 
the  injected  vessels  stood  out  prominently  from  the  cleared 
parenchyma.  The  plasticity,  so  obtained,  eliminated  many 
sources  ol  error.  The  objections  to  this  method,  however,  wen- 


4  THE  BLOOD  SUPPLY  TO  THE  HEART 

again  those  of  individual  differences,  lack  of  standardization 
of  technique,  as  well  as  the  inability  to  render  thick  organs 
sufficiently  transparent  to  allow  complete  visualization  of  the 
whole  circulatory  tree.  Nevertheless,  to  this  method  we  owe  the 
excellent  observations  made  by  Spalteholz  on  the  heart 
(1907).  He  employed  a  chrome-yellow  gelatine  with  subsequent 
clearing. 

B.     TECHNIQUE     EMPLOYED    IN    THESE    STUDIES 

As  all  these  methods  had  their  good  points  and  since 
each  had  its  especial  application,  the  author  has  used  a  com- 
bination in  somewhat  modified  form. 


Fig.   1. — Flanged  glass  nozzle. 

By  employing  a  simple  apparatus  in  which  every  element 
of  technique  could  be  accurately  measured  and  standardized, 
uniform  injections  were  obtained  with  a  barium  sulphate  sus- 
pension in  gelatine  (tide  infra).  After  injection,  the  hearts 
were  roentgenographed  stereoscopically,  cleared,  and  finally  dis- 
sected and  sectioned. 

A  separate  series  of  hearts  was  injected  for  the  purpose  of 
following  out  by  serial  section  the  minute  circulatory  structure. 

The  apparatus  used  (Fig.  3)  has  proven  eminently  satis- 
factory, so  that  its  uniform  results  rendered  comparative  work 
thoroughly   reliable. 

The  hearts  are  injected  forty-five  hours  after  death  to 
allow  rigor  to  pass  off.  The  chambers  are  previously  washed 


TECHNIQUE  5 

free  from  clot  and  cannulae  inserted  into  the  orifices  of  the 
coronary  arteries. 

In  the  ease  of  large  hearts,  large  cannulae  are  used.  These 
are  made  by  coating  an  ordinary  pin  with  graphite,  inserting 
this  into  the  point  of  a  glass  nozzle,  heating  the  tip  until  red 
and  then  flattening  down  on  a  hard  smooth  surface.  The  pin, 
which  meanwhile  has  preserved  the  lumen,  can  now  be  with- 
drawn. In  this  way  a  flange  is  formed  at  the  end  of  the  nozzle 
(Fig.  1). 

In  the  case  of  infants'  hearts,  cannulae  are  made  by  solder- 
ing a  thin  rim  of  silver  around  a  No.  20  gauge  2-inch  hypoder- 
mic needle  and  filing  off  the  point  beyond  it  (Fig.  2). 


Fig.  2.     Flanged  metal  needle. 

I  he  loose  cellular  tissue  on  the  external  surface  ot  the  aorta 
just  at  the  point  of  emergence  of  each  coronary  is  bluntly 
dissected  with  a  pair  of  hemostatic  forceps  until  the  whole 
circumference  of  the  vessel  is  cleared.  A  silk  thread  is  now 
tied  around  the  artery  as  close  as  possible  to  the  point  oi 
emergence,    the   flange   of  the   needle   being   below   the   loop. 

Rubber  tubing  is  placed  on  the  cannulae  and  these  are  con- 
nected by  a  "  Y"  tube. 

The  heart  is  then  suspended  by  inserting  a  glass  rod  under 
the  bridge  of  the  pericardium  which  lies  between  the  great 
\essels   and   the   auricles,   and    resting   this   rod   on   a   tripod. 

The  tripod  is  placed  in  the  upper  chamber  of  the  apparatus 
which  consists  of  a  wooden  box  lined  with  copper.  Separating 


6  THE  BLOOD  SUPPLY  TO  THE  HEART 

it  into  two  chambers  (upper  and  lower)  is  a  pan  which  has  an 
outflow  tube  connecting  it  to  the  outside.  In  the  center  of  the 
pan  are  two  openings,  necked  to  prevent  dripping  into  the 
lower  chamber. 


"A. 

air  pus 

"D, 


Fig.  3. — Injection  apparatus. 
Compressed  air  tank  which  blows  air  into  "B,"  chamber  which  registers  the 
ire  by  means  of  manometer  "C." 

Pressure  tube  which  can  be  attached  to  either  "E,"  inlet  tube  of  saline  flask, 
or  "F,"  inlet  tube  of  injection  mass  bottle.  By  this  means  saline  can  be  forced  out  of 
flask  "G,"  into  spiral  tube  "H,"  which  is  being  heated  by  the  immersibie  electric  heater 
"J."  The  saline  is  thus  forced  out  of  spiral  "H,"  through  tube  "L,"  into  bottle  "M," 
where  the  temperature  is  registered  by  thermometer  "N."  Tube  "O"  conducts  the 
saline  through  cannulae  to  the  organ.  Similarly,  by  applying  pressure  tube  "D"  to  "F," 
the  injection  mass  can  be  forced  out  of  bottle  "P,"  through  "Q,"  into  the  cannula. 
"R"  is  the  out-flow  tube. 
"S"  is  another  immersibie  electric  heater. 

"T"  and  "U"  are  thermometers  for  registering  the  temperature  of  the  chambers. 
"V"  is  a  glass  window  for  observing  the  condition  of  the  injecting  organ. 
"\V"  is  an  electric  illuminating  bulb.    (Organ   for   injection    is  suspended  from  a 
tripod  in  the  upper  chamber.) 


Outside  the  incubator  is  a  Wolff  ilask.  Into  this,  com- 
pressed air  is  forced  until  an  attached  mercury  manometer 
registers  150  mm.  Hg  (or  whatever  pressure  it  is  desired  to  use 
in  the  injection).  The  pressure  tube  from  this  bottle  is  con- 
nected to  a  large  ilask  containing  normal  saline.  The  saline  is 
therefore    forced   out  of  the  flask  into  a  spiral  tube  in  the 


TECHNIQUE 

lower  chamber,  which  is  immersed  in  a  bath  kept  warm  by  an 
electric  immersion  heater.  From  here,  it  is  conducted  into 
the  upper  chamber  into  a  small  Wolff  llask  which  contains  a 
thermometer.  The  temperature  of  the  saline  is  thus  accurately 
determined  before  it  is  forced  into  the  blood-vessels. 

By  raising  or  lowering  the  spiral  tube  in  the  water-bath, 
the  temperature  can  be  altered  to  any  degree  desired. 

The  saline  at  the  proper  temperature  is  now  forced  through 
the  coronary  arteries  until  the  washings  come  clear. 

The  whole  incubator  is  kept  at  uniform  heat  by  another 
immersion  electric  heater,  a  thermometer  being  placed  in  each 
chamber.  Electric  bulbs  and  glass  doors  render  it  quite  easy  to 
observe  the  progress  of  the  injection. 

When  the  blood-vessels  are  washed  quite  clean,  the  pres- 
sure tube  from  the  manometer  bottle  is  attached  to  a  Wolfl 
llask  containing  the  injection  mass  which  has  been  kept  in  the 
lower  chamber.  The  mass  is  forced  into  the  vessels  until  the 
mercury  in  the  manometer  remains  constant  at  150  mm. 
without  requiring  additional  compression.  The  vessels  are 
then  tied  off,  the  cannulae  removed,  and  the  heart  immersed 
in  cold  water. 

A  suction  apparatus  attached  to  the  tap  is  now  used  to 
suck  out  and  wash  the  chambers  of  the  heart  free  from  any 
accumulated  injection  mass. 

The  heart  is  then  immersed  in  cold  formalin  until  fixed 
and  bleached  when  it  is  ready  lor  stereoscopic  roentgenograms 
which  should  be  taken  with  a  tube  of  medium  spark  gap. 
(Dr.  Morgan  employs  the  following  roentgenographic  technique: 
Tube  distance,  24  inches;  stereoshift,  2^  inches  and  40; 
tube,  4-5  inch  spark  gap;  time,  '  j  0  to  1  second  exposure 
according  to  size;  duplitized   films,   not    screened;   20   m.   a. 


8  THE  BLOOD  SUPPLY  TO  THE  HEART 

Dr.  H.  H.  Cheney  suggests  that  in  very  difficult  cases  where 
the  shadows  to  be  cast  are  very  fine,  the  best  results  would 
be  procured  by  a  technique  which  calls  for  longer  exposures 
and  a  very  small  amount  of  x-rays.) 

For  clearing,  the  heart  is  gradually  dehydrated  in  alcohol, 
commencing  with  50  per  cent  and  changing  every  alternate 
day  into  an  alcohol  of  10  per  cent  additional  strength  until 
absolute.  After  the  heart  has  remained  two  days  in  absolute 
alcohol,  the  concentration  of  the  latter  is  tested  with  an  alco- 
holometer, and  if  the  reading  is  below  99  per  cent  another 
change  into  absolute  is  made  until  finally  the  reading  remains 
between  99  and  100  per  cent.  Methylated  spirits  have  proven 
quite  satisfactory  for  the  dehydration. 

The  heart  may  now  be  immersed  in  synthetic  oil  of  winter- 
green.  Clearing  commences  almost  immediately.  On  account 
of  discoloration  it  may  be  necessary  to  change  into  a  fresh 
quantity  of  the  oil.  In  two  to  three  days  the  organ  is  rendered 
quite  clear  and  excellent  photographs  can  be  taken  of  the 
specimen  completely  submerged  in  the  oil  of  wintergreen. 
(For  this  purpose,  use  panchromatic  plates  with  an  amber 
filter.) 

Dissections  are  in  this  way  rendered  simple,  since  practi- 
cally all  branches  and  even  branchlets  are  quite  visible  and 
can  be  followed  out  minutely. 

Barium  Sulphate  Gelatine.  The  injection  mass  em- 
ployed in  this  method  is  made  up  as  follows: 

Soak  300  gm.  of  a  fine  French  gelatine  (preferably  Gold 
Label)  for  two  hours  in  1,200  c.c.  of  distilled  water.  To  this  add 
1,000  gm.  of  finely  powdered  barium  sulphate,  500  c.c.  of 
distilled  water  and  2  gm.  of  thymol.  Heat  over  a  water-bath 
until  the  gelatine  dissolves   and  stir   until   the  whole    mass 


TECHNIQUE  9 

becomes  a  homogeneous  milky  lluicl.  Filter  through  two  layers 

of  Victoria  [awn. 

If  pigmented  gelatines  arc  to  be  used,  the  same  technique 
is  employed.  The  gelatine  is  mack'  up  as  follows: 

Carmine  Gelatine.  Allow  100  gm.  of  gelatine  to  soak 
for  two  hours  in  200  c.c.  of  distilled  water.  Warm  over  a 
water-bath  until  the  gelatine  dissolves  and  filter  through  two 
layers  of  Victoria  lawn.  It  is  advisable  to  place  the  filter  in  an 
incubator  to  prevent   the  jelly   from  setting  while  filtering. 

Dissolve  15  gm.  of  aqueous  soluble  carmine  (Grubler's, 
if  possible)  in  300  c.c.  of  distilled  water.  Slowly  add  6  c.c. 
of  ammonia,  stirring  continually.  Filter  through  two  layers  of 
Victoria  lawn. 

Now  mix  the  filtrate  with  the  filtered  jelly.  Add  about 
4  c.c.  of  acetic  acid  to  the  mixture,  or  to  be  exact,  an  amount 
which  by  previous  titration  has  been  found  just  sufficient  to 
neutralize  6  c.c.  of  ammonia.  Add  1  gm.  of  thymol. 

Filter  once  more  through  two  thicknesses  of  Victoria 
lawn.  With  this  medium,  capillary  injections  can  be  easily 
accomplished  and  frozen  serial  sections  can  be  quite  success- 
fully   obtained.    These    are    mounted    in    Farrant's    solution. 

Prussian-Blue  Gelatine.  Proceed  as  with  carmine 
gelatine,  substituting  15  gm.  of  soluble  Prussian-blue  for  the 
carmine.  It  is  not  necessary  to  render  alkaline  and  neutralize. 
(On  the  whole  this  has  proven  less  satisfactory  than  carmine 
gelatine. ) 

Bayne-Jones  suggests  that  in  order  to  obtain  a  thorough 
penetration  of  the  gelatine  into  the  capillaries  (e.g.,  those  in 
valves),  it  is  necessary  to  tie  off  all  the  cut  edges  of  the  heart, 
as  well  as  the  mouth  of  the  coronary  sinus.  He  uses  a  1  ]  ■_.  per 
cent    carmine  solution    in   gelatine  warmed   to  45°  C.   and  in- 


io  THE  BLOOD  SUPPLY  TO  THE  HEART 

jects  at  a  pressure  of  140  to  190  mm.  Hg.,  the  heart  being 
immersed  in  a  salt  solution  at  500  C. 

Where  it  is  desired  subsequently  to  cut  sections  of  rapidly 
autolysing  and  changing  tissue,  e.g.,  nodal  tissue,  or  where  it  is 
required  to  avoid  waiting  two  days  for  rigor  to  pass  off,  a  10  per 
cent  solution  of  potassium  sulphocyanide  (as  recommended 
by  McCordick)  is  allowed  to  trickle  through  the  coronaries 
for  about  one  hour.  In  this  way,  paralysis  and  dilatation  of  the 
vessels  quickly  occur  and  the  organ  can  immediately  be  in- 
jected. Similarly,  for  roentgenography  it  is  not  necessary  to  fix 
the  tissues,  but  the  organ  should  be  placed  into  ice-cold  forma- 
lin until  the  gelatine  is  set. 

In  order  to  inject  the  veins  of  the  heart,  two  methods  may 
be  employed:  one  is  to  place  a  cannula  into  the  sinus  coro- 
narius;  the  other,  by  means  of  which  excellent  injection  of  the 
venae  parvae  and  venae  minimae  cordis  may  also  be  obtained, 
is  to  tie  a  cannula  into  the  superior  vena  cava,  tie  off  all  other 
exits  from  the  right  side  of  the  heart,  inject  directly  into  the 
right  auricle,  freeze  the  gelatine  and  carefully  remove  the 
contents  of  the  chambers.  In  venous  injection,  a  relatively 
low  pressure  should  be  employed. 

In  order  to  obtain  contrasting  colors  for  arteries  and  veins 
or  between  both  coronaries,  carmine  gelatine  may  be  added  to 
the  barium  suspension  in  the  proportion  of  1  to  10. 


Chapter  II 
The  Blood  Supply  to  the  Ventricles  and  Auricles 

IN  commencing  a  description  oi  the  distribution  of  the 
coronary  arteries  to  the  auricles  and  ventricles,  the 
author  is  at  once  confronted  with  the  difficulty  of  describ- 
ing a  structure  which  varies  not  only  in  different  hearts,  but 
also,  as  we  shall  see  later,  in  the  different  age  periods. 

In  order  to  overcome  these  difficulties  it  has  been  decided 
to  give  a  description  of  a  theoretical  heart  whose  ventricular 
and  auricular  supply  represents  an  average  reconstruction 
from  a  study  of  one  hundred  normal  specimens. 

Since  the  variations  are  in  themselves  of  considerable 
anatomical  interest,  however,  both  physiologically  and  patho- 
logically, statistical  analysis  of  the  hearts  will  also  be  given. 

The  description  which  follows  is  divided  into  two  groups: 
(A)  Superficial  Divisions;  which  represent  the  main  branches 
with  their  subdivisions  usually  to  the  first,  second  and  third 
order.  In  this  part  of  their  course  they  are  superficial  and  can 
easily  be  seen  under  the  pericardium.  After  this,  however, 
they  penetrate  the  bulk  of  the  heart  musculature  in  a  manner 
which  will  be  described  later,  and  are  known  as  (B)  the 
Deeper  Divisions. 

A.    SUPERFICIAL    DIVISIONS 

Figure  4  is  a  roentgenogram  of  an  approximately  average 

heart.1  It  is  seen  that  it  is  supplied  by  two  coronary  arteries, 

a  right  and  a  left. 

'The  roentgenograms  reproduced  in  this  monograph  give  a  view  of  tin  cardiac  circula- 
tion as  il  Mm  from  tin-  back  so  that  one  looks  through  and  through  tin  arterial  tree 
The  right  side  oi  th<  plate  represents  accordingly  the  right  side  of  the  heart  and  tin-  left 
side  of  tin-  plate  represents  the  hit  side  of  the  heart. 


ia  THE  BLOOD  SUPPLY  TO  THE  HEART 

The  right  coronary  artery  arises  from  the  aorta  slight Iy 
below  the  level  of  the  right  anterior  aortic  cusp.  From  here  it 
proceeds  directly  to  the  right  and  emerges  on  the  anterior 
surface  between  the  roots  of  the  aorta  and  pulmonary  arteries. 
Hugging  the  auriculoventricular  sulcus,  it  rounds  the  margo 
acutus,  passes  that  situation  of  the  heart  posteriorly  where 
the  auricles  and  ventricles  meet,  known  as  the  crux,  and 
finally  terminates  halfway  between  the  latter  and  the  margo 
obtusus.  Here  it  descends  about  two-thirds  of  the  way  down 
the  posterior  surface  of  the  left  ventricle  in  perpendicular 
fashion. 

In  its  passage  around  the  auriculoventricular  groove, 
the  coronary  artery  is  called  the  Arteria  circumflexa  dextra. 
It  is  occasionally  bridged  by  strands  of  heart  muscle.  Through- 
out its  course  it  gives  off  branches  to  auricles,  ventricles  and 
adjacent  fat. 

The  first  ventricular  branch  is  a  delicate  arcuate  twig 
which  is  constantly  found  crossing  the  root  of  the  pulmonary 
artery  to  anastomose  with  a  similar  branch  from  the  left 
coronary  artery  (Fig.  24).  Its  site  opposite  the  insertions 
of  the  pulmonary  cusps  defines  accurately  the  junction  of  the 
conus  with  the  pulmonary  artery  and  may  be  of  some  embryo- 
genetic  significance. 

On  the  anterior  surface  of  the  right  ventricle,  two  main 
branches  descend  to  the  lower  third  of  the  heart.  In  their 
course  they  give  off  a  number  of  more  or  less  parallel  twigs 
which  extend  horizontally  to  the  left  as  far  as  similar  branches 
from  the  ramus  descendens  of  the  left  coronary  artery 
and  anastomose  with  them.  Horizontal  twigs  also  extend  to 
the  right  as  far  as  the  margo  acutus. 

A    constant    stout    lateral    branch    (Ramus    lateralis)   de- 


Fig,  4. — Roentgenogram  of  the  blood  supply  in  the  average  heart. 


13 


BLOOD  SUPPLY  TO  VENTRICLES  AND  AURICLES      i$ 

sccnds  along  the  margo  acutus  towards  the  apex.  At  the  lower 
third  of  the  ventricle  it  often  turns  posteriorly  and  extends 
transversely  across  the  posterior  surface  of  the  right  ventricle 
to  reach  the  posterior  interventricular  sulcus. 

The  next  constant  branch  to  be  given  off  is  the  ramus 
descendens  posterior.  This  takes  origin  at  the  crux  and  descends 
along  the  interventricular  furrow  posteriorly  until  it  reaches 
the  lower  third  of  the  ventricle  (Fig.  25). 

The  terminal  portion  of  the  right  coronary  artery  now 
divides  into  two  or  three  branches  (Rami  ventriculares  sinis- 
tri),  which  descend  on  the  posterior  surface  of  the  left  ventricle. 

The  lejt  coronary  artery  arises  from  the  left  anterior  sinus 
of  Valsalva  just  a  little  below  the  level  of  the  free  edge  of  the 
corresponding  aortic  cusp.  Proceeding  directly  forward  and 
to  the  left,  it  soon  bifurcates  under  cover  of  the  left  auricular 
appendage.  One  large  and  constant  division,  the  ramus 
descendens  anterior  sinister,  is  seen  emerging  on  the  anterior 
surface  of  the  heart  between  the  root  of  the  pulmonary  artery 
and  the  left  auricular  appendage.  Descending  along  the 
anterior  interventricular  furrow,  it  rounds  the  apex  and 
ascends  the  posterior  interventricular  furrow  to  reach  the 
lower  third  of  the  ventricles.  Throughout  its  course  this 
branch  supplies  numerous  transverse  twigs  to  the  anterior 
surfaces  of  the  right  ventricle,  as  well  as  large  branches  which 
course  diagonally  down  and  around  the  margo  obtusus  (Rami 
marginales)  and  maintain  a  more  or  less  parallel  relationship 
to  one  another. 

Of  the  latter,  one  branch  is  very  constant  and  character- 
istic in  its  course,  though  not  so  fixed  in  its  origin.  Arising 
generally  from  the  ramus  descendens  anterior  sinister,  some- 
times from  the  fork  between  it  and  the  second  main  division 


1 6  THE  BLOOD  SUPPLY  TO  THE  HEART 

of  the  left  coronary  artery,  and  less  frequently  from  the  latter, 
it  is  the  most  prominent  of  this  group  of  lateral  branches 
and  its  terminal  divisions  sink  into  the  musculature  as  they 
reach  the  posterior  surface  of  the  left  ventricle. 

The  second  main  division  of  the  left  coronary  artery 
(Ramus  circumflexus  sinister)  lies  in  the  auriculoventricular 
sulcus  and  emerges  from  beneath  the  left  auricular  appendage 
to  become  superficial  where  the  margo  obtusus  gives  way  to  the 
posterior  surface  of  the  left  ventricle.  Here  it  takes  a  more  or 
less  abrupt  downward  bend,  supplying  in  its  arborizations 
the  upper  posterior  portion  of  the  left  ventricle  in  a  fashion 
similar  to  the  other  rami  marginales  on  the  margo  obtusus  of 
which  it  forms  another  branch. 

B.    THE    DEEPER    DIVISIONS 

The  description  thus  far  given  takes  no  account  of  many 
other  important  branches  and  divisions.  Of  these,  one  of  the 
most  important  groups  is  that  of  the  deeper  branches. 

With  the  exception  of  the  ramus  descendens  anterior  and 
posterior,  all  the  other  large  coronary  branches  display  their 
main  divisions  on  the  anterior  surface  of  the  heart.  If  one 
were  to  pierce  the  heart  with  a  knitting  needle  from  its  apex 
to  a  point  corresponding  to  the  center  of  the  base,  generally 
speaking,  the  main  coronary  subdivisions  of  the  second  and 
third  order  could  be  said  to  arrange  themselves  in  a  circular 
manner  around  the  external  surface  of  the  heart  transverse 
to  the  needle  as  an  axis. 

From  this  point  on,  the  finer  arborizations  are  dichotomous 
and  soon  plunge  into  the  heart  muscle  in  a  direction  at  right 
angles  to  the  surfaces  of  the  ventricles.  As  the  ultimate  arbori- 
zations approach  the  internal  surface  of  the  heart  they  abruptly 


Fig.  5. — Photograph  of  injected  and  cleared  specimen,  showing  the  ulti- 
mate subendocardial  distribution  of  the  coronary  arteries. 


THE  BLOOD  SUPPLY  TO  THE  VENTRICLES  19 

resume  a  course  parallel  to  it,  and,  in  richly  interanastomosing 
meshes  which  on  the  whole  have  a  longitudinal  arrangement 
and  tend  to  follow  the  intricacies  of  the  columnac  carnae, 
spend  themselves  macroscopically  under  the  endocardium 
I  Fig.  5).  The  ultimate  capillary  distributions  follow  the 
direction  of  the  muscle  libers,  so  that  long  parallel  delicate 
capillaries  lying  in  the  interstices  between  the  individual 
libcis  show  here  and  there  a  short  crossing  and  connecting 
link  of  capillary  whose  length  corresponds  to  the  width  of  a 
liber.  We  have  not  found  with  Meigs  that  capillaries  penetrate 
through  muscle  libers,  but  that,  as  held  by  Koster,  capillaries 
surround  individual  muscle  fibers. 

The  papillary  muscles  are  turgid  with  delicate  vessels 
which  penetrate  them  through  and  through,  preserving 
throughout  a  longitudinal  arrangement  with  stepladder-like 
anastomoses.  These  mount  to  the  apex  of  the  muscle  both  in  its 
main  mass  as  well  as  on   its  surface,  as  described  by  Ribbert. 

The  two  rami  desccndcntcs  of  the  coronary  arteries,  as 
already  indicated,  have  a  somewhat  different  distribution. 
In  addition  to  the  branches  which  they  distribute  on  the  sur- 
face of  the  heart  and  which  divide  and  subdivide  in  a  fashion 
similar  to  other  branches,  they  possess  divisions  which  pene- 
trate directly  through  the  interventricular  septum  (Rami 
interventriculares),  arranging  themselves  more  or  less  in  the 
manner  of  harp  strings  (Fig.  4),  those  from  the  ramus  de- 
scendens  posterior  dexter  spreading  out  anteriorly,  and 
anastomosing  with  similar  branches  from  the  ramus  descend- 
ens  ante]  ior  sinister. 

The  general  arrangement  of  these  branches  is  parallel 
w  ith  tlu'  base  of  the  heart. 

The  subdivisions    from    these   follow    in   their  ultimate  dis- 


20  THE  BLOOD  SUPPLY  TO  THE  HEART 

tribution  the  same  course  and  character  as  described  for 
those  of  the  ventricular  wall. 

It  is  noteworthy  that  the  topmost  of  these  rami  inter- 
ventriculares  (Ramus  septi  fibrosi)  arises  from  the  ramus 
circumflexus  dexter  at  the  crux,  proceeds  anteriorly  along 
the  region  between  the  interventricular  and  interauricular 
septa  and  supplies,  in  its  finest  ramifications,  the  tissue  in  and 
around  the  opening  of  the  coronary  sinus  (Fig.  8).  It  extends 
from  this  situation  anteriorly,  anastomoses  with  a  correspond- 
ing branch  from  the  left  coronary  artery  and  penetrates 
through  the  central  fibrous  body  and  undefended  space  (Pars 
membranacea  septi). 

The  auricular  branches  of  both  coronary  arteries  do  not 
show  as  constant  an  arrangement  as  the  ventricular  supply, 
nevertheless,  there  are  certain  characteristic  features  worthy 
of  note. 

There  are,  as  a  general  rule,  two  auricular  branches  which 
arise  from  the  anterior  portion  of  the  arteria  circumflexa 
dextra  (Rami  anteriores) .  The  first  of  these  arises  as  a  stout 
branch  very  soon  alter  the  origin  of  the  right  coronary  artery 
and,  coursing  at  once  posteriorly,  reaches  the  anterior  wall  of 
the  right  auricle  and  follows  this  as  it  curves  behind  the  aorta, 
maintaining  a  horizontal  position  about  half  a  centimeter 
above  the  auriculo-aortic  groove  (Figs.  4  and  8).  Reaching 
the  site  of  the  interauricular  septum,  it  gives  oft  several 
twigs  which  surround  the  upper  portion  of  the  right  auricle 
anteriorly  and  supply  the  appendage  and  adjoining  regions, 
whereas  the  main  vessel  turns  abruptly  posteriorly  and  passes 
through  the  septum  to  reach  the  posterior  portion.  Here,  it 
turns,  and,  ascending  the  superior  wall  of  the  right  auricle 
posteriorly  to  the  cava  insertion,  it  surrounds  in  ring  fashion 


THE  BLOOD  SUPPLY  TO  THE  VENTRICLES         21 

the  site  of  junction  of  the  superior  vena  cava  with  the  auricle 
(Sulcus  terminalis)  and  arborizes  extensively  in  the  tissue  in 
and  around  the  auriculoventricular  node. 

Throughout    its    course,    this    vessel    gives    and    receives 

numerous  anastomosing  twigs  with  the  other  auricular 
branches.  As  will  he  shown  later,  it  may  arise  from  the  left 
coronarx  artery,  in  which  case  its  course  is  as  follows: 

Arising  very  close  to  the  origin  of  the  left  coronary  artery, 
often  from  its  posterior  mam  division,  it  either  encircles  the 
base  of  the  left  auricular  appendage,  ascending  tin-  external 
surface  of  the  left  auricle  and  crossing  directly  to  the  region 
of  thi'  superior  vena  cava  where  it  terminates  in  a  manner 
similar  to  that  described  lor  the  right  coronary  origin  of  this 
vessel,  or  it  passes  back  immediately  alter  its  origin  so  as  to 
course  along  the  anterior  wall  of  the  left  auricle  about  hall  a 
centimeter  above  the  auriculo-  aortic  groove.  When  it  reaches 
t  he  site  of  the  interauricular  septum,  it  turns  up  and  crosses  on 
tin-  superior  aspect  of  the  right  auricle,  between  the  superior 
cava  funnel  and  the  right  appendage,  ultimately  to  attenuate 
itself  around  the  opening  of  the  inferior  vena  cava  in  a  manner 
which  is  described  in  greater  detail  in  Chapter  IV. 

Throughout  its  course,  it  too,  -i\  es  ofl  numerous  anastomo- 
tic twigs,  and,  particularly  as  it  crosses  the  roof  of  the  right 
auricle,  gives  numerous  arborizations  to  the  seat  of  the  sino- 
auricular  nodal  tissue. 

This  most  constant  and  probably  most  important  auricular 
branch  s|u>ws  s,>  characteristic  a  course  that  it  merits  the  name 
of  Ramus  ostii  Cavae  superioris. 

The  second  anterior  branch  to  the  auricles  from  the  right 
coronarj  arterj  i^  less  constant.  It  ascends  the  aortic  face 
of  the  right  auricular  appendage  and  distributes  itself  o\  er  the 


22  THE  BLOOD  SUPPLY  TO  THE  HEART 

roof  of  the  right  auricle,  approaching  the  origin  of  the  superior 
vena  cava. 

Very  occasionally  a  lateral  branch  is  given  off  at  the 
margo  acutus,  which  ramifies  over  the  external  surface  of  the 
right  auricle,  approaching  the  opening  of  the  inferior  as  well  as 
that  of  the  superior  vena  cava. 

A  number  of  very  small  and  inconstant  auricular  vessels 
may  be  seen  besides  those  described  above,  but  since  there  is 
nothing  characteristic  about  these  and  since  they  are  with 
difficulty  distinguishable  from  vessels  which  supply  the 
pericardial  fat,  the  description  of  these  will  be  taken  up  under 
the  heading  of  Arteriae  telae  adiposae  cordis. 

The  left  coronary  artery  shows,  with  the  exception  of 
the  ramus  ostii  cavae  superioris  already  described,  one  or  two 
smaller  auricular  branches  which  distribute  themselves  over 
the  anterior  surface  and  roof  of  the  left  auricle.  Occasionally  a 
lett  lateral  auricular  branch  extends  around  the  posterior 
surface  of  the  auricle  to  reach  the  opening  of  the  superior 
vena  cava. 

ARTERIAE   TELAE    ADIPOSAE    CORDIS 

Besides  the  main  vessels  which  have  thus  far  been  de- 
scribed, there  are  a  number  of  interesting  and  important 
branches  which  apparently  occupy  both  anatomically  and 
functionally  a  category  of  their  own,  because  considered  from 
both  these  viewpoints  they  seem  to  occupy  a  place  half  way 
between  that  of  the  vasa  vasorum  and  the  cardiac  coronary 
branches  proper. 

These  are  what  may  be  called  fat  branches  (Arteriae 
telae  adiposae).  They  are  seen  in  greatest  number  in  the  fat 
found  under  the  pericardium — namely,  in  the  grooves  between 


THE  BLOOD  SUPPLY  TO  THE  VENTRICLES         25 

the  chambers,  where  they  occur  as  an  irregular  felt-work, 
and  over  the  sites  of  the  main  coronary  branches,  where  they 
exist  as  delicate  parallel  accompanying  vessels  whose  distance 
from  the  main  branches  varies  directly  with  the  amount  of  fat 
present  (Figs.  24  and  25).  The  rich  interanastomosing  network 
of  delicate  vessels,  superimposed  upon  the  outer  coats  of  the 
root  of  the  aorta  and  of  the  pulmonary  artery,  falls  under  this 
category.  These  fat-vessels  arise  largely  from  the  first  portions 
of  the  arteria  circumflexa  sinistra  and  dextra  as  well  as  from 
their  branches  soon  after  their  origin. 

In  a  later  chapter  their  importance  and  significance  will  be 
shown. 

BLOOD    SUPPLY    TO    THE    HEART    AS    A    WHOLE 

It  is  of  considerable  interest  and  importance  to  coordinate 
the  description  giver  afc>0"\  e  of  tin'  distribution  of  the  individual 
coronary  arteries  and  consider  the  supply  of  the  heart  as  a 
whole  as  well  as  of  its  specific  parts. 

Numerous  investigators  have  attempted  to  inject  both 
coronary  arteries  at  the  same  time,  and,  by  using  a  differently 
colored  injection  mass  for  each  coronarx  artery,  have  obtained 
results  which  in  some  measure  help  to  throw  light  on  those 
regions  of  the  heart  which  are  supplied  by  both. 

Amenomiya,  Nussbaum  and  Sternberg  have  contributed 
much  valuable  information  in  this  direction. 

It  must  first  of  all  be  remembered  that  there  can  be  no 
sharp  line  of  demarcation  between  the  supply  of  right  and 
left  coronarj  arteries,  since,  not  only  do  their  branches  OS  crlap, 
but  also,  as  will  later  be  shown,  profuse  and  abundant  anas- 
tomoses leave  a  wick-  borderline  which  is  supplied  by  both 
vessels.     A  rather  arbitrary   division  will  therefore  be  given, 


24 


THE  BLOOD  SUPPLY  TO  THE  HEART 


first,  of  the  supply  of  each  artery;  secondly,  of  the  common 
supply  by  both  vessels. 

Since  the  auricular  distribution  of  blood-vessels  is  so 
prone  to  variations  that  an  attempt  at  giving  a  typical  descrip- 
tion becomes  artificial  and  practically  worthless,  this  will  be 
left  to  the  consideration  of  variations.  The  following  descrip- 
tion, therefore,  answers  in  a  rather  unsatisfactory  way  for 
the  supply  to  the  ventricles. 


Fig.  6. — Diagram   of  cross  section   through   the   heart,  showing  regions 
supplied  by  the  [eft  and  right  coronary  arteries. 

Lines  running  from  right  to  left  represent  the  supply  of  the  left  coronary  artery. 
Lines  running  from  left  to  right  represent  the  supply  of  the  right  coronary  artery. 
The  crossed  areas  represent  supply  from  both  vessels. 

From  the  description  which  has  been  given  above,  it  can 
readily  be  appreciated  that  the  right  coronary  artery  in  the 
typical  average  heart  supplies  the  entire  right  ventricle  with 
the  exception  of  the  left  third  of  the  anterior  wall.  Besides 
this,  its  rami  ventriculares  sinistri  supply  the  right  half  of 
the  posterior  wall  of  the  left  ventricle  and  a  small  strip  of 
the  interventricular  septum  (Fig.  6). 


THE  BLOOD  SUPPLY  TO  THE  VENTRICLES         25 

The  left  coronary  artery,  on  the  other  hand,  supplies 
the  whole  remaining  part  of  the  left  ventricle-,  the  small  [eft 
anterior  portion  of  the  right  ventricle  not  supplied  by  the 
right  coronary  artery  and  a  small  anterior  strip  of  the  inter- 
ventricular septum. 

The  areas  of  junction  on  the  posterior  surface  of  the  left 
ventricle  and  on  the  anterior  surface  of  the  right  ventricle 
where  these  divisions  meet,  are  supplied  by  both  vessels. 
Thus,  the  intervening  portion  of  the  interventricular  septum 
is  supplied  by  branches  from  the  ramus  descendens  posterior 
dexter  and  ramus  descendens  anterior  sinister  and  the  pos- 
terior papillary  muscle  of  the  left  ventricle  by  the  rami  ventricu- 
Iares  sinistri  from  the  right  and  the  rami  marginales'from  the  kit 
coronary  artery.  At  least  a  portion  of  the  anterior  papil- 
lary muscle  of  the  right  ventricle  is  supplied  from  the  rami  inter- 
\  entriculares  from  the  left  and  the  rami  anteriores  fromthe  right 
corona  1  \  artery.  Indeed,  it  is  quite  easy  to  trace  a  distinct 
large  \  cssel  through  the  trabecula  septomarginal  to  this 
papillary  muscle,  which  appears  to  supply  the  greater  volume 
of  its  blood  to  this  region. 

The  large  anterior  papillary  muscle  oi  the  [eft  ventricle 
receives  its  blood  from  the  rami  marginales  and  the  inconstant 
posterior  papillary  muscle  of  the  right  ventricle  from  the  rami 
posteriores  of  the  right  coronary  artery. 


Chapter  III 
Variations  in  the  Distribution  of  the  Coronary  Arteries 

AS  has  been  indicated,  the  coronary  arteries  are 
rather  prone  to  variations.  It  is  this  disposition  to 
variations  which  renders  their  description  somew  hat 
artificial  and  rigid.  There  appears,  however,  to  be  one  typical 
variation  which  is  rather  constant  and  which  will  be  described 
here.  For  the  reason  that  the  other  possible  variations  assume 
clinical  and  pathological  interest,  a  table  classifying  a  statis- 
tieal  analytical  study  of  the  course  and  character  of  the 
coronary  arteries  will  follow. 

If  one  makes  a  review  comparing  the  general  characteristics 
of  the  average  distribution  of  left  and  right  coronary  arteries, 
one  is  struck  by  the  fact  that  the  main  stout  ramus  descendens 
anterior  of  the  left  coronary  artery  has  its  counterpart  in  the 
ramus  descendens  posterior  of  the  right;  furthermore,  that  the 
left  coronary  artery  seems  to  trespass  on  the  anterior  surface 
of  the  right  ventricle  and  falls  somewhat  short  of  supplying 
completely  the  left  ventricle  posteriorly. 

The  main  scheme,  therefore,  in  so  far  as  the  ventricular 
supply  is  concerned,  seems  to  be  a  sort  of  twisting  of  the  vessels 
in  a  direction  from  left  to  right  anteriorly  and  right  to  Ieit 
posteriorly. 

An  examination  of  what  is  termed  the  typical  variation 
(Fig.  7)  shows,  first  of  all,  that  both  the  anterior  and  posterior 
rami  descendentes  come  from  the  left  coronary;  secondly, 
that  the  rather  aborted  ramus  circumflexus  sinister,  which  is 

26 


Fie.    7. — Roentgenogram     of    a    typical    variation    in   coronary    artery 
dirtribution. 


27 


VARIATIONS  IN  THE  CORONARY  ARTERIES        29 

seen  in  the  normal  heart,  is  represented  here  by  a  verj  typical 
and  characteristic  circumflex  branch  which  imitates  accurately 
that  found  normally  on  the  right  side.  Thus,  even  the  branches, 
which  have  been  described  as  originating  for  the  most  part 
from  the  fork  of  the  two  main  corollaries  normally,  in  tins 
instance  arise  from  the  left  coronary  artery  all  along  its  course 
through  the  auriculoventricular  sulcus  and  up  to  a  point 
where  it,  again  imitating  the  right  coronary  artery,  abruptly 
bends  downward  at  the  site  of  the  crux  and  proceeds  to  the 
lower  third  of  the  heart.  The  third  striking  feature  is  the  verj 
much  aborted  and  simplified  right  coronary  artery.  The  ramus 
circumilexus,  now  resembling  that  normally  found  on  the  [eft 
side,  ends  at  the  margo  acutus  and  gives  oil  some  delicate 
branches,  one  of  which  continues  in  the  auriculoventricular 
sulcus  towards  the  crux,  the  others  presenting  a  rather  scant 
supply  oxer  the  posterior  face  of  the  right  ventricle.  The  main 
body  of  the  right  coronary  turns  abruptly  down  at  the  margo 
acutus  and  finally  attenuates  itself  toward  the  apex.  For  the 
rest,  the  subdivisions  of  this  vessel  on  the  anterior  surface  ol  the 
light  ventricle  is  similar  to  that  found  in  the  normal. 

The  auricular  supply  in  this  type  shows  no  characteristic 
variation. 

STATISTICAL    ANALYSIS    OF    THE    VARIATIONS 

The  site-  of  origin  of  the  coronary  arteries  shows  consider- 
able variation.  Since,  as  Tandler  points  out,  the  old  discussion 
between  Morgagni  and  Fantoni  and  later  between  Ilyrtl 
and  Brticke,  as  to  the  importance  of  the  site  of  opening  oi  the 
COronarj  arteries  in  connection  with  the  position  ol  the 
semilunar  cusps  in  systole,  has  lost  its  significance,  it  is  suffi- 
cient   to   state   with    Piquand    that    they    arise    in    the    center 


30  THE  BLOOD  SUPPLY  TO  THE  HEART 

line  of  the  sinus  of  Valsalva  somewhat  anteriorly  to  the  inser- 
tion of  the  cusps. 

So  far  as  the  number  of  the  coronary  arteries  at  their 
origin  is  concerned,  it  is  interesting  to  note  that  Morgagni, 
Cruveilhier,  HyrtI,  Bochdalek  and  Engelmann  have  described 
cases  where  the  total  blood  supply  to  the  heart  came  from  a 
singly  existing  coronary  artery. 

Fallopius  and  Riolanus  held  that  normally  one  coronary 
artery  exists  in  the  heart.  Morgagni,  however,  showed  that 
two  exist. 

Occasionally  more  than  two  coronary  arteries  spring  from 
the  aorta.  In  such  instances  the  accessory  branch  or  branches 
represent  twigs  which,  in  the  ordinary  course  of  events, 
spring  from  the  main  coronary,  but  which,  in  these  cases,  arise 
directly  from  the  aorta  close  to  the  origin  of  the  main  stem. 

Tandler  states  that  this  multiple  origin  of  coronaries  is 
found  on  both  sides,  more  frequently  on  the  left.  Out  of  the 
ioo  cases  studied  by  the  author,  in  four  instances  a  second 
origin  of  a  coronary  artery  was  seen;  of  these,  two  were  on  the 
left  side  and  two  on  the  right.  Here  the  accessory  coronary 
pursues  a  course  identical  with  one  of  the  rami  ventriculares 
anteriores.  The  accessory  openings  in  the  left  anterior  sinus  of 
Valsalva  were  somewhat  to  the  left  of  the  opening  of  the  main 
coronary  artery.  Of  those  on  the  right  side,  one  arose  to  the 
left,  and  the  other,  below  and  to  the  right  of  the  main  coronary 
artery. 

That  this  condition  occurs  more  frequently  than  reported 
and  is  often  missed,  seems  quite  possible,  since  the  accessory 
coronary  branch  is  usually  very  small  and,  unless  a  careful 
dissection  is  made  or  an  injection  directly  down  the  lumen  of 
the  aorta  carried  out,  the  condition  can  easilv  be  overlooked. 


DISTRIBUTION  OF  THE  CORONARY  ARTERIES     31 

Although  occurring  relatively  infrequently,  the  condition 
assumes  some  clinical  importance,  for  an  obliteration  of  a 
main  coronary  artery  which  [eaves  intact  an  accessory  twig 
may  enable  a  heart,  which  has  had  time  to  adapt  itself  to  the 
diminution  in  its  blood  supply,  to  carry  on  a  relatively  un- 
disturbed function. 

VARIATIONS   IN    IIU-:  MAIN  BRANCHES 

In  considering  the  variations  occurring  in  the  main 
branches  of  the  coronary  arteries,  it  has  been  decided  to 
present  these  in  table  form.  This  can  conveniently  be  expressed 
by  categorizing,  according  to  their  site  of  origin  and  main 
course,  the  branches  in  the  100  hearts  which  were  very  care- 
fully studied,  indicating  the  percentage  in  which  they  occurred 
singly,  as  two  branches,  three,  etc. 

In  the  text  which  follows  each  chart,  a  more  detailed 
discussion  on  the  qualitative  nature  of  the  variations  is  given. 

TABLE  I.— ARTERIA  CORONARIA  DEXTRA 


SUPPLY    TO    VENTRICLES 


Number  ctf  Branches 

0 

1 

2  | 

3 

4 

5 

4 

$6 

47 

13 

0 

0 

«H 

I     6 

84 

8 

2 

0 

0 

■-  Z 

Rami  Ventriculares  Dextri  Posteriores. 

48 

4o 

8| 

0 

4 

0 

1     8 

92 

o| 

0 

0 

0 

-  - 

,6 

J  2 

22  | 

18 

1(1 

2 

- 

TABLE  II.— TERMINATION  OE  RAMUS  CIRCUMFLEXES 
DEXTER 


Margo  Acutus 

Crux 

Between  Crux 

and 
Margo  Obtusus 

Margo  Obtusus 

4    pel     Kill 

10  per  cent 

'id  per  cent 

20  per  0  nt 

32  THE  BLOOD  SUPPLY  TO  THE  HEART 

Where  several  rami  anteriores  exist,  they  course  somewhat 
diagonally  across  the  anterior  surface  of  the  right  ventricle 
and  approach  the  ramus  descendens  sinister  at  right  angles. 
In  their  course  they  are  parallel  and  relatively  equidistant  to 
one  another.  They  do  not  dichotomise  with  frequency  in  their 
main  stems  but  rather  towards  the  end  of  their  course  on  the 
surface  of  the  heart. 

Where  the  rami  anteriores  occur  in  smaller  numbers,  they 
proceed  in  a  line  drawn  to  the  apex,  giving  off  all  the  while 
parallel  and  more  or  less  equidistant  branches  to  the  right  and 
principally  to  the  left  side  in  a  manner  very  similar  to  those 
described  above. 

The  ramus  lateralis,  as  will  be  seen  in  Table  I,  occurs  most 
frequently  singly.  Here  it  descends  in  somewhat  tortuous 
fashion  towards  the  apex,  divides  before  reaching  it  and 
distributes  branches  to  the  anterior  and  posterior  aspect  of  the 
lower  portion  of  the  right  ventricle. 

The  rami  posteriores  are  infrequent.  Occurring  usually 
singly,  they  have  a  short  course  parallel  to  the  ramus 
lateralis. 

The  ramus  descendens  posterior  terminates  in  5  per  cent 
of  the  cases  at  the  upper  third  of  the  posterior  Interventricular 
sulcus,  in  27  per  cent  at  the  middle,  in  39  per  cent  in  the 
lower  third,  and  in  20.  per  cent  at  the  apex. 

When  the  rami  ventrfculares  sinistri  occur  multiple,  they 
are  given  off,  as  a  general  rule,  fairly  close  one  to  the  other  near 
the  crux,  spending  themselves  in  their  coarser  distribution 
on  the  inner  and  upper  half  of  the  posterior  surface  ot  the  left 
ventricle. 

Of  the  termination  of  the  ramus  circumllexus  dexter  (Table 
II),  it  need  only  be  said  that  66  per  cent  end  somewhere  between 


DISTRIBUTION  OF  THE  CORONARY  ARTERIES     33 

the  crux  and  the  margo  obtusus.  Of  these,  41  per  cent  end  hall- 
way between  the  two  points. 

TABLE  III.— ARTERIA  CORONARIA  DEXTRA 

SUPPLY   TO    AURICLES 


0         .    1     2 

3 

Rami  Anteriores 

|    1 1   |  52  |  26 

11 

■= 

Kami  Laterales 

|  62  |  36  |     2 

0 

M  = 

Kami  Auricula  res  Dextri  Posteriores 

79       16  |     5 

0 

^    = 

Rami  Auriculares  Sinistri  Posteriores 

|  84  |    12  |     4 

0 

- 

As   has   been   pointed   out   before,   with   the  exception   of 

the  stout  branch  to  the  junction  of  the  superior  vena  cava  with 
the  right  auricle  {Ramus  ostii  cavse  superioris),  the  auricular 
branches  are  rather  inconstant  in  their  distribution.  In  a  great 
number  of  cases  the  branches  are  so  small  that  the  borderline 
between  those  which  may  be  called  auricular  branches,  and 
those  which  fall  into  the  category  of  fat  branches,  is  \cr> 
uncertain.  It  is  noteworthy  that,  although  both  auricular  as 
well  as  fat  branches  usually  arise  from  the  main  ramus  circum- 
llexus,  the\  also  take  origin  from  the  beginning  of  the  ventricu- 
lar branches. 

As  will  be  seen  by  the  nomenclature  (Table  III),  the  divi- 
sion of  these  branches  into  groups  according  to  their  site  of 
origin  is  purely  arbitrary,  since  this  may  not,  and  often  does 
not,  correspond  with  their  ultimate  distribution.  Thus,  a 
ramus  auricularis  sinister  posterior  is  occasionally  seen  to  cross 
the  region  of  the  interauricular  septum  from  left  to  right  and 
ultimately  to  arborize  on  the  right  side  of  the  right  auricle. 
Indeed,  it  is  not  infrequently  found  that  the  vessels  pursue  a 
bizarre  course  and  supply  at  random  almost  any  conceivable 
portion  ol  the  auricles  irrespective  ol  the  original  site  ol  origin. 


34 


THE  BLOOD  SUPPLY  TO  THE  HEART 


It  is  true,  however,  that  to  a  certain  extent  a  branch  will  supply 
that  portion  of  the  auricle  which  it  first  crosses  and  in  this 
way  there  is  some  correlation  between  the  nomenclature  and 
the  function  of  the  vessel. 

It  is  on  account  of  this  rather  inconstant  supply  of  these 
vessels  that  it  has  been  decided  to  give,  at  the  end  of  this 
chapter,  an  analysis  of  the  blood  supply  to  the  auricles  in 
bulk,  that  is,  stating  approximately  the  ratio  of  auricles  sup- 
plied from  the  left  and  right  coronary  arteries. 


TABLE  IV.— ARTERIA  CORONARIA  SINISTRA 

SUPPLY    TO   VENTRICLES 


Number  of  Branches 

0 

1 

2 

3 

4 

5 

6 

Ramus  Descendens  Anterior 

0 

100 

0 

0 

0 

0 

0 

0 

6 

23 

45 

14 

6 

6 

Rami  Posteriores 

84 

8 

6 

2 

0 

0 

0 

=  3 

Ramus  Descendens  Posterior 

92  | 

8 

0 

0 

0 

0 

0 

0  c 

Ramus  Ventricularis  Dexter 

92  | 

7 

0 

1 

0 

0 

0 

TABLE  V.— TERMINATION  OF  RAMUS  DESCENDENS 
ANTERIOR 


Lower  Third  of 

Lower  Third  of 

Middle  of 

Anterior 

Apex 

Posterior 

Posterior 

Interventricular 

Interventricular 

Interventricular 

Sulcus 

Sulcus 

Sulcus 

2  per  cent 

38 

per  cent 

52  per  cent 

8  per  cent 

TABLE  VI.— TERMINATION  OF  RAMUS  CIRCUMFLEXUS 
SINISTER 


I    Between  Margo 
Margo  Obtusus  j  Obtusus 

Crux 


86  per  cent 


2  per  cent 


Crux 


10  per  cent 


Between  Crux 

and 

Margo  Acutus 

2  per  cent 


DISTRIBUTION  OF  THE  CORONARY  ARTERIES     35 

Here  it  must  be  noted,  first,  that  the-  ramus  descendens 
anterior  gives  a  number  of  branches  to  the  right  ventricle, 
which  run  in  the  same  direction  and  meet  the  rami  anteriores 
from  the  right  coronary  artery.  Secondly,  the  rami  marginis 
obtusi,  which  are  represented  on  the  right  side  by  the  rami 
anteriores  and  Iaterales,  arise,  as  pointed  out  before,  somewhere 
on  tlie  left  ventricular  aspect  of  the  ramus  descendens  and 
ramus  circumllcxus  sinister.  The  variations,  here,  are  charac- 
terized by  a  shifting  of  their  site  of  origin  anywhere  from  the 
extent  of  the  ramus  descendens  to  the  ramus  circumllcxus  as  far 
as  the  junction  of  the  margo  obtusus  with  the  posterior  surface 
of  the  left  ventricle. 

The  greater  number  of  these  diagonally  running  vessels 
come  oil  the  ramus  descendens,  the  lowermost  terminating 
their  superficial  course  on  the  anterior  surface  of  the  left 
ventricle  in  the  region  of  the  apex.  The  remainder,  together 
with  those  taking  origin  from  the  ramus  circumllcxus,  round 
the  margo  obtusus  to  reach  the  posteroexternal  portion  ol  the 
[eft  \  entricle. 

There  are  usually  one  or  two  branches  from  the  ramus 
circumllcxus  opposite  the  center  of  the  margo  obtusus,  which 
are  larger  than  the  remaining  rami  marginales  and  which 
extend  downward  towards  the  apex. 

Tlie  first  characteristic  variation  to  be  considered  is  the 
termination  of  the  ramus  descendens  anterior.  It  will  be  seen 
in  Table  V  that  the  site  of  election  is  the  lower  third  of  the 
posterior  interventricular  furrow.  In  tins  regard  it  is  to  be 
remembered  that  the  final,  minute  termination  extends  much 
farther.  The  place,  however,  where  the  superficial  and  coarser 
circulation   ends   has   been    used   as   the   point    of  termination. 

In   (S4   per  cent   of  the  eases   there   were    no  distinct    rami 


36  THE  BLOOD  SUPPLY  TO  THE  HEART 

posteriores  and  in  these  cases  the  posterolateral  surface  of 
the  left  ventricle  was  supplied  by  continuations  of  the  rami 
marginis  obtusi. 

Rami  descendentes  posteriores  occurred  only  in  instances 
where  the  ramus  circumllexus  reached  the  crux.  In  the  same 
instances  rami  ventriculares  dextri  were  given  off,  usually 
only  one;  in  one  case,  three  (Table  IV). 

TABLE  VII.— ARTERIA  CORONARIA  SINISTRA 

SUPPLY   TO    AURICLES 


|     0 

i 

2 

3 

|     5  | 

45  1 

27  | 

23 

|   77 

23    | 

<) 

0 

erf  C 

Rami  Auriculares  Sinistri  Posteriores 

|  86 

14 

0 

0 

1   Si  = 

Rami  Auriculares  Dextri  Posteriores 

|     0 

0 

0 

0 

i  0. 

The  same  remarks  as  to  the  inconstancy  in  course  and 
character  of  the  auricular  branches,  which  were  made  for  the 
rami  auriculares  from  the  arteria  coronaria  dextra,  apply 
equally   well   to    those    from   the    arteria   coronaria   sinistra. 

It  will  be  noted  in  Table  VII  that  there  are  no  branches 
arising  from  that  part  of  the  ramus  circumllexus  sinister  which 
occasionally  (in  2  per  cent  of  cases,  Table  VI)  extends  beyond 
the  crux  to  the  right  side.  This,  of  course,  does  not  mean  that 
auricular  branches  from  the  left  coronary  artery  do  not  extend 
over  to  the  right  side,  for  this  is,  as  a  matter  of  fact,  not  infre- 
quently seen. 

Upon  examining  the  roentgenograms  carefully,  it  was  found 
that  in  44  per  cent  of  the  cases  most  of  the  circulation  to 
both  auricles  came  from  the  right  coronary  artery;  in  36  per 
cent  of  the  cases,  the  distribution  of  auricular  branches  and 
vascular  structure  was  about  equal  from  the  right  and  left 


DISTRIBUTION  OF  THE  CORONARY  ARTERIES     37 

corollaries,  and  in  20  per  tent  ol  the  cases  most  of  the  blood 
came  from  the  left  coronary  artery. 

It  is  interesting  to  note,  in  this  connection,  what  an  impor- 
tant role  the  ramus  ostn  cava'  supcrioris  plays,  for  in  82  per 
cent  ol  those  cases  winch  showed  a  preponderance  oi  supply 
from  the  right  side,  then'  existed  a  ramus  ostii  cavae  supcrioris 
taking  origin  from  the-  right  coronary  artery.  In  100  per  cent 
ol  the  cases  where  the  preponderant  supply  was  from  the  lelt 
coronary  artery,  the  ramus  ostii  cavae  supcrioris  arose  from 
tin  same  side.  Taken  altogether,  the  ramus  ostii  arose  from  the 
right  coronary  artery  in  60  per  cent  of  the  cases,  and  from  the 
left  in  40  per  cent. 

From  the  foregoing  description  of  the  variations  which 
occur  in  the  branching  and  ultimate  distribution  ol  the 
coronary  arteries,  it  follows  that  the  heart  as  a  whole,  as  well 
as  its  parts,  e.g.,  septum  and  papillary  muscles,  presents 
functional  differences  corresponding  to  these  variations,  an 
observation  which  is  rather  important  clinically  and  anatomi- 
cally, lor,  whereas  for  example,  in  the  typical  blood  supply 
an  infarction  and  necrosis  of  the  posterior  papillary  muscle  of 
the  left  side  would  indicate  a  closure  of  branches  from  both 
sides,  m  the  typical  variation  which  has  been  described,  closure 
ol  one  or  two  rami  postcriorcs  from  the  left  coronary  alone 
would  cause  the  same  condition.  Again,  when  the  ramus 
circumflexus  dexter  reaches  the  margo  obtusus  (20  per  cent  1, 
obliteration  ol  it  alone  would  lead  to  a  total  necrosis  ol  that 
muscle;  as  also  with  the  supply  to  the  interventricular 
septum. 

The  most  frequent  seat  of  variations,  so  far  as  suppb  from 
lelt  or  right  is  concerned,  lies  in  the  extent  of  supply  to  the 
posterior  wall  of  the  heart.  As  has  been  noted,  this  ma\    vary 


38  THE  BLOOD  SUPPLY  TO  THE  HEART 

from  cases  where  branches  from  the  left  coronary  artery  extend 
practically  to  the  margo  acutus,  to  where  branches  from  the 
right  coronary  artery  extend  to  the  margo  obtusus.  In  these 
instances  the  region  of  the  heart  supplied  by  each,  as  well  as 
the  region  of  the  heart  receiving  blood  from  both,  will  vary 
with  the  anatomy  of  the  circulatory  structure. 


Chapter  IV 
The  Blood  Supply  to  the  Neuromuscular  Tissue 

IN  describing  the  blood  supply  to  the  conducting  apparatus 
of  the  heart,  to  which,  among  others,  notable  contribu- 
tions have  been  made  by  Purkinje,  Gaskell,  Kent,  W.  His, 
Jr.,  Keith  and  black,  Aschoff  and  Tawara,  Moenckeberg, 
Koch,  Fahr,  Hering  and  Erlanger,  it  is  deemed  advisable  to 
give  a  short  description  of  this  structure  in  order  to  review  its 
morphology  and,  therefore,  appreciate  better  the  specificity 
of  its  vascular  architecture  as  well  as  the  functional  significance 
of  the  latter. 

This  structure  which,  despite  the  objections  by  some 
observers,  as  Dogiel,  is  now  held  to  be  responsible  lor  the 
orderly  origin  and  conduction  ol  impulses  from  auricles  to 
ventricles,  consists  of:  (a)  two  mam  nodes  which  are,  according 
to  Thorel,  united  by  a  specially  differentiated  strand  of  tissue, 
but,  according  to  Keith  and  Hack  and  Koch,  ununited  except 
b\  the  ordinary  musculature  ol  the  auricles;  b)  a  main 
auriculoventricular  conducting  bundle  which  divides  into  two 
limbs  lor  right  and  left  ventricles;  (c)  a  very  rich  and  profuse 
arborization  ol  the  limbs  in  both  ventricles. 

Ol  the  two  main  nodes,  one,  known  as  the  sino-auricular, 
Ins  in  the  sulcus  at  the  [unction  ol  the  superior  vena  cava 
with  the  right  auricle,  more  on  its  anterior  aspect.  The  other, 
known  as  tin-  auriculoventricular  node,  lies  within  the  mouth, 
and  extends  t<>  the  lelt  ol  the  opening  ol  the  sinus  coronarius 
into  the  right  auricle.  It  is  certain  that  the  mam  conducting  or 

S9 


4o  THE  BLOOD  SUPPLY  TO  THE  HEART 

His  bundle  is  a  direct  continuation  of  the  latter,  which,  lying 
in  a  sheath  (described  by  Curran)  penetrates  the  septum 
fibrosum.  This  is  from  i  to  3  mm.  in  width  and  1  to  2  cm.  in 
length  and  usually  runs  along  the  lower  border  of  the  pars 
membranacea  septi  where  it  divides  into  a  right  and  left 
septal  branch  which  saddle  the  top  of  the  interventricular 
septum.  The  right  limb  extends  into  the  vestigial  moderator 
band  (Trabecula  septomarginalis,  Ta-ndler)  as  a  fairly  distinct 
column  which  may  or  may  not  course  superficially.  Here  it 
breaks  up  into  an  extensive  interlacing  and  interanastomosing 
network  of  fibers  which  are  generously  distributed  over  the 
internal  surface  of  the  right  ventricular  wall. 

The  left  limb  passes  over  the  top  of  the  interventricular 
septum  and,  soon  spreading  into  a  fan-shaped,  thin  and  fiat 
structure,  distributes  itself  over  the  interior  surface  of  the  left 
ventricle  in  two  divisions.  These  are  called,  according  to  their 
location  on  the  interventricular  septum,  fasciculus  anterior  and 
fasciculus  posterior. 

So  far  as  the  histology  of  this  structure  is  concerned, 
it  may  be  stated  briefly  that  the  nodes  and  main  bundle  are 
made  up  of  a  meshwork  of  narrow,  somewhat  fusiform  fibers 
with  more  or  less  indistinct  striations.  These  cells  gradually 
give  way,  as  they  ramify  in  the  ventricles,  to  large  pale  fibers 
of  relatively  undifferentiated  protoplasm  with  striations 
clearly  seen  in  their  outer  strata.  The  nuclei  of  the  main 
bundle  are  numerous  and  always  surrounded  by  a  perinuclear 
space;  those  of  the  ultimate  ramifications  never  occur  together 
and  are  always  near  the  border  of  the  cells. 

In  1907  Keith  and  Flack  first  pointed  out  that  the  sino- 
auricular  node  possesses  a  distinct  and  specific  blood  vascular 
system.  This  was  substantiated  in  1909  by  Koch,  who  described 


BLOOD  SUPPLY  TO  NEUROMUSCULAR  TISSUE      41 

in  greater  detail  a  stout  branch  from  the  right  coronary  artery  , 
which  courses  between  the  aorta  and  mesial  wall  of  the  right 
auricle  to  penetrate  the  interauricular  septum  and  sends  a 
twig  to  surround  posteriorly  the  cava  sulcus.  Here  it  anas- 
tomoses with  a  delicate  auricular  branch  which  arises  from 
the  mam  coronary  in  this  situation  and  ascends  between 
the  musculae  pectinati,  passing  practically  free  through  the 
interstices.  The  vessels  now  pass  the  situation  of  Wenckebach's 
bundle  and  pierce  through  the  sino-auricular  node. 

In  [906  Tawara  described  a  special  blood  supply  to  the 
auriculoventricular  node,  the  main  bundle  and  its  chief  divi- 
sions. This  was  later  described  by  Keith  and  Flack  as  a 
relatively  large  branch  ol  the  right  coronary  artery  which  accom- 
panies the  main  bundle  as  it  penetrates  the  annulus  librosus. 

Moenckeberg  (1908)  described  vessels  supplying  the  auri- 
culoventricular node  and  the  main  bundle  but  did  not  consider 
them  specific  or  constant  in  their  supply.  He  had  seen  a  thick 
\  essel  emerging  from  the  auricular  septum  to  enter  the  bundle 
and  divide  into  many  small  vessels  which  accompany  the  stem 
ol  the  bundle  forward.  From  these,  two  branches  continue  to 
the  anterior  portion  of  the  bundle  up  to  the  point  of  division. 

Spalteholz  (1909)  observed  a  delicate  vessel  entering  the 
bundle    but    was    unable    to    determine    its    ultimate    course. 

In  [910  Georg  Haas  published  the  results  of  his  researches 
in  this  direction,  lie  employed  differently  colored  injection 
masses  lor  each  coronary  artery,  filling,  in  some  cases,  a 
single   coronarj    artery;    in   others,    both   at   the  same   time. 

Isolating  what  he  believed  to  be  the  specific  branch  to  the 
auriculoventricular  nodal  system,  he  also  attempted  to  inject 
this  branch  alone,  but  was  unsuccessful  on  account  of  technical 
difficulties. 


42  THE  BLOOD  SUPPLY  TO  THE  HEART 

Haas's  experiments  consisted  in  injections,  dissections  and 
serial  sections  of  human,  dogs'  and  calves'  hearts,  and  from 
these  he  came  in  part  to  the  following  conclusions: 

In  man  the  right  coronary  artery  plays  the  chief  role,  supplying  two 
branches  from  the  posterior  coronary  arch.  First,  a  ramus  septi  ventri- 
culorum  superior,  which  supplies  the  upper  posterior  half  of  the  septum, 
piercing  into  the  left  ventricle  and  supplying  the  posterior  divisions  of 
the  neuromuscular  limb  in  this  situation.  Secondly,  a  ramus  septi  fibrosi 
which,  coursing  through  the  auricular  septum,  sends  several  branches 
through  the  septum  fibrosum  to  the  inner  muscular  layers  of  both  ventricles 
and  finally,  as  a  stout  twig,  enters  Tawara's  node  and  loses  itself  in  the 
main  bundle  and  beginnings  of  both  neuromuscular  limbs.  The  anterior 
branches  to  the  left  main  limb  are  supplied  by  fine  twigs  from  the  left 
coronary  artery;  the  right  limb  lies  just  on  the  border  between  the  regions 
of  arborization  of  the  right  and  left  coronary  arteries  in  the  septum. 

He  is  of  the  firm  opinion  that  in  the  human  heart,  no 
anastomoses  exist  between  the  right  and  left  coronary  arteries 
in  the  auriculoventricular  node  and  main  bundle. 

From  a  study  made  on  ioo  hearts,  the  author  is  of  the 
opinion  that  a  distinct  and  specific  blood  supply  exists  for  both 
sino-auricular  and  auriculoventricular  nodes,  the  main  bundle, 
the  first  portion  of  the  left  limb  and  a  large  part  of  the  right  limb 
of  the  neuromuscular  system.  The  remainder  shows  a  supply 
which  corresponds  to  the  area  of  heart  musculature  upon  which 
it  rests. 

The  discrepancies  in  the  otherwise  excellent  work  oi 
Haas  are  probably  due  to  technical  errors,  Haas  himself 
admitting  difficulties.  Dissections  in  an  uncleared  specimen, 
even  though  perfectly  injected,  are  at  best  open  to  error,  and 
serial  sections,  though  throwing  much  light  on  the  microscopic 
appearance  of  capillaries,  etc.,  are  eminently  unreliable  for 
coarser  reconstruction. 


Fig.  8. 


Photograph  <>!  injected  and  cleared  specimen,  showing  the  blood 
supply  to  the  neuromuscular  tissue  on  the  right  side. 


P. 


NEUROMUSCULAR  TISSUE  45 

Figure  8  shows  an  injection  by  the  method  described  by  the 
author  in  the  chapter  on  technique.  Here  it  is  seen  quite 
clearly  that  a  very  stout  and  characteristic  branch  which 
arises  close  to  the  origin  of  the  right  coronary  artery,  in  this 
case  makes  a  fairly  direct  course  for  the  region  of  the  sino- 
auricular  node  and  is  called,  on  account  of  its  obviouslj  specific 
supply,  the  Ramus  ostii  cava  superioris.  As  its  detailed  de- 
scription has  already  been  given  (Chapter  II),  it  need  only 
be  pointed  out  that  though  this  vessel  is  more  or  less  character- 
istic in  its  ultimate  supply,  it  is  not  absolutely  fixed  in  its 
origin,  for  it  may  arise  from  either  left  or  right  coronary  arterj  . 
Furthermore,  the  author  has  been  unable  to  find  the  character- 
istic twig  which  Koch  describes  as  arising  from  the  main 
coronary  close  to  the  origin  of  the  inferior  vena  cava  and 
passing  practically  free  through  the  interstices  of  the  muscular 
pectinati,  but  has  found  instead: 

First,  that  several  auricular  branches  in  the  vicinity  give 
oil  numerous  anastomotic  twigs;  secondly,  the  ramus  ostii 
cavae  superioris  shows  extensive  anastomoses  with  its  own 
branches;  thirdly,  in  certain  instances  where  the  ramus  ostii 
cavae  superioris  arises  from  the  left  coronary  artery  mot 
pointed  out  by  Koch)  it  may  either  supply  the  nodal  tissue 
only  as  it  passes  this  site  anteriorly,  other  auricular  branches 
contributing  largely  to  the  ring-shaped  encircling  arterial 
structure,  or,  it  may  bifurcate  as  it  reaches  the  cava  funnel 
and  encircle  it  with  two  embracing  branches  which  anastomose 
freely  with  each  other  as  well  as  with  other  auricular  branches 
in  the  region  of  the  external  surface  of  the  right  auricle; 
fourthly,  the  author  has  failed  to  find  a  \  essil  which  lies,  on  the 
whole,  free  in  the  interstices  of  the  musculac  pectinati. 

rhere  are  never  two  rami  ostii  cavae  superiores,  always 


46  THE  BLOOD  SUPPLY  TO  THE  HEART 

one.  No  blood-vessels  have  been  found  to  show  a  supply  for  a 
specific  tissue  which  might  connect  the  sino-auricular  with 
the  auriculoventricular  node,  an  observation  which  is  confirm- 
atory of  Koch's. 

Figure  8aIso  shows  the  ramussepti  jibrosi.  This  corresponds, 
except  for  a  few  details,  very  well  with  the  description  given 
by  Haas.  It  arises  invariably  from  the  crux,  and  since  this 
is  crossed  most  frequently  by  the  ramus  circumilexus  of  the 
right  coronary  artery,  it  receives  its  blood  usually,  though 
not  invariably,  from  this  source. 

Coursing  directly  anteriorly  it  gives  branches  to  the 
neighboring  tissues,  one  of  which,  usually  a  stout  twig,  is 
fairly  constantly  seen  supplying  the  superior  portion  of  the 
interventricular  septum.  The  main  (though  occasionally  more 
delicate)  vessel,  however,  plunges  into  the  auriculoventricular 
node  and  accompanies  this  as  it  gives  way  to  the  main  bundle, 
and  often  the  bundle  in  its  primary  divisions. 

Just  as  the  ramus  septi  fibrosi  represents  really  a  superior 
septal  branch  from  the  ramus  descendens  posterior,  even  so  its 
behavior  is  similar  to  these,  inasmuch  as  it  receives  anas- 
tomoses from  the  superior  septal  branches  of  the  left  coronary 
artery. 

These  septal  branches  can  readily  be  seen  in  a  cleared 
specimen.  They  curve  close  under  the  insertion  of  the  right 
aortic  cusp,  in  the  musculature  of  the  interventricular  septum, 
sometimes  better  seen  on  the  left  side,  and  approaching  the 
undefended  space,  ramify  in  the  neuromuscular  tissue  in  the 
septum  iibrosum,  anastomosing  with  the  corresponding  vessel 
from  the  right  side. 

The  main  point  of  difference  in  the  circulation  as  de- 
scribed here,  with  that  of  Haas,  lies  in  the  existence  of  anas- 


NEUROMUSCULAR  TISSUE  47 

tomoses  which  take  place-  between  branches  from  the  left  as 
well  as  the  right  coronary  arteries. 

In  a  case  cited  by  Haas  this  anatomical  construction  is 
borne  out.  This  concerns  a  heart  where  there  occurred  em- 
bolization of  the  ramus  septi  fibrosi  with  hemorrhagic  infarc- 
tion oi  the  interauricular  septum  and  the  muscular  divisions 
which  enter  into  the  nodal  structure.  The  anterior  portion  of 
the  node  was  preserved  though  much  altered  by  inflammation. 
Here,  Haas  states,  perhaps  anastomoses  occurred  with  the 
ramus  superior  septi  ventriculorum  or  with  the  anterior  septal 
artery. 

The  right  limb  ol  the  neuromuscular  bundle,  as  has  been 
stated,  pursues  a  practically  uninterrupted  course  through  the 
trabecula  septomarginalis.  Throughout,  it  is  accompanied 
by  a  stout  vessel  {Ramus  limbi  dextri)  derived  from  one  of 
the  earliest  divisions  of  the  ramus  descendens  sinister,  and 
really  representing  a  septal  branch.  At  the  base  of  the  trabec- 
ula, twigs  from  the  rami  anteriores  ol  the  right  coronary 
aitcr  \    penetrate  and   anastomose  with  the  ramus  limbi  dextri. 

The  ultimate'  arborizations  are  supplied  from  the  rich 
subendocardial  vessels  which  have  been  described  on  page  10, 
and  correspond  in  their  nutrition  with  the  area  ol  heart 
musculature  upon  which  they  lie. 

The  left  limb  of  the'  neuromuscular  structure  has  no  specific 
blood  supply  ol  its  own,  but  derives  its  nourishment  on  its 
septal  aspect  from  the'  profuse  anastomoses  of  septal  branches 
from  both  siele's,  the  fasciculus  anterior  receiving  more  blood 
from  the'  ielt  coronary  artery,  and  the  fasciculus  posterior, 
from  the'  right.  For  the'  rest,  here,  as  in  the  right  ventricle,  the 
ultimate'  divisions  \ar\  in  their  blood  supply  according  to  their 
situation  on  the'  heart   musculature. 


48  THE  BLOOD  SUPPLY  TO  THE  HEART 

It  is  important  to  remember  that  variations  in  the  vascular 
architecture  will  profoundly  alter  the  blood  supply  to  the 
neuromuscular  tissue. 

It  has  already  been  pointed  out  that  the  sino-auricular 
node  is  supplied  from  the  right  coronary  artery  in  60  per  cent 
of  the  cases  examined,  and  from  the  left,  in  40  per  cent. 
Since  the  ramus  septi  fibrosi  arises  from  that  coronary  artery 
which  passes  the  crux,  it  follows  that  its  origin  is  as  follows: 

(a)  Right  Coronary  Artery 86  per  cent 

(b)  Left  Coronary  Artery 4  per  cent 

(c)  Possible  from  left  or  right 10  per  cent 

The  percentage  of  possibilities  from  left  or  right  is  due 
to  the  fact  that  this  figure  represents  the  proportion  of  cases 
where  both  left  and  right  ramus  circumflexus  reach  the  crux. 
In  these  cases,  6  per  cent  of  the  possibilities  came  from  the 
right  and  4  per  cent  from  the  left,  so  that  the  final  figures  are: 

(a)  Right  Coronary  Artery 92  per  cent 

(b)  Left  Coronary  Artery 8  per  cent 

As  with  the  ramus  ostii  cavae  superioris,  this  branch 
always  arises  from  one  side,  never  from  both. 

Since  no  variations  were  found  in  the  occurrence  of  the  rami 
interventrieulorum  from  the  ramus  descendens  anterior  sinis- 
ter, at  least  in  our  cases,  it  maybe  assumed  that  the  Iimbus  dex- 
ter of  the  neuromuscular  tissue  invariably  derives  its  blood  from 
the  left  coronary  artery. 

So  far  as  the  blood  supply  of  the  fasciculi  of  the  Iimbus 
sinister  on  their  septal  aspect  is  concerned,  in  those  cases 
where  the  ramus  descendens  posterior  arose  from  the  left 
coronary  artery  (8  per  cent)  they  were  supplied  wholly  from 


NEUROMUSCULAR  TISSUE  49 

tin's  artery.  This,  as  will  be  noted,  corresponds  to  the  ratio  ol 
supply  to  the  auriculoventricular  node  from  the  same  side. 
In  the  other  <)2  per  cent,  both  coronary  arteries  contributed  to 
their  supply. 

The  ultimate  distribution  of  the  Purkinje  libers  also  corre- 
sponds, as  regards  their  blood  supply,  to  the  variations  described 
in  Chapter  III. 

To  bring  out  the  clinical  and  pathological  importance  ol 
this  vascular  arrangement,  as  well  as  to  lend  support  to  the 
anatomical  description,  there  follows  a  series  of  eases  described 
by  Moenckeberg,  in  which  distinct  pathological  lesions  ol  the 
neuromuscular  structure  are  traced  to  interference  with  its 

Specific  blood  supply. 

It  is  already  well  known  that  this  tissue  at  times  shares 
pathological  processes  with  the  rest  of  the  heart  musculature; 
at  times  escapes;  and,  at  times,  is  the  sole  part  affected  in 
generalized  hematogenous  disl  urbances. 

Moenckeberg,  lor  example,  has  shown  that  in  a  ease  ol 
endo-  and  focal  myocarditis,  a  distinct  infiltration  and  con- 
gestion ol  the  neuromuscular  tissue  occurred. 

In  some  eases  of  brown  atrophy,  the  bundle  contained  fat 
and  much  more  brown  pigment  than  the  muscular  tissue 
proper. 

One  east'  of  arteriosclerosis  and  brown  atrophy  ol  the 
heart    showed    an   absence  of  pigment    in    the   limbus  sinister. 

In  a  male,  aged  seventy-seven,  who  died  ol  pyelonephritis, 
heart  failure  and  brown  atrophy  of  the  heart,  the  bundle  was 
very  fatty  but  contained  no  brown  pigment. 

Moenckeberg  attributes  this  discrepancj  in  the  pigmenta- 
tion of  the  bundle  to  the  fact  that  pigmentation  must  be 
advanced  before  it  affects  the  bundle. 


5o  THE  BLOOD  SUPPLY  TO  THE  HEART 

In  another  case  dying  from  general  peritonitis,  fatty  rings 
were  found  only  in  the  bundle.  It  is  to  be  remembered  that 
normally  the  bundle  contains  fat. 

In  a  case  of  thoracic  mesaortitis  with  stenosis  ol  a  coronary 
artery,  there  was  no  necrotic  lesion  in  the  bundle.  This  case 
assumes  particular  significance  when,  by  contrast,  a  series  is 
examined  where  this  bundle  artery  has  been  blocked.  Thus,  in 
a  male,  aged  eighty-two,  who  ''lowed  clinically  the  Stokes- 
Adams  syndrome  with  bradycardia  and  dissociation,  and  who 
presented  at  autopsy  a  heart  with  concentric  hypertrophy  ol 
the  left  ventricle  and  considerable  sclerosis  of  the  main 
coronary  arteries  with,  however,  patent  lumina,  a  scar  was 
found  at  the  site  of  the  bundle.  As  Moenckeberg  could  find  no 
other  explanation  for  this,  other  than  embolic  blocking,  he 
came  to  the  conclusion  that  "this  condition  is,  however,  only 
to  be  explained  by  assuming  a  distinct  and  specific  artery  to 
the  bundle,  and  in  this  way  the  above  case  supports  the  view 
that  the  blocked  bundle  must  have  contained  a  specific  vessel." 

In  Case  xxiv  of  Moenckeberg's  series,  there  is  an  interest- 
ing illustration  of  the  specificity  of  supply  to  the  bundle. 
In  an  individual,  aged  sixty-three,  who  died  with  arterio- 
sclerotic kidney,  there  was  found  arteriosclerosis  of  the  coro- 
naries  with  old  closure  of  the  right  and  many  scars  in  the 
heart  muscle.  The  septum  in  the  region  oj  the  bundle  was  scarred, 
but  the  bundle  itself  was  intact.  Here  evidently  the  vasculature 
to  the  bundle  was  functioning  perfectly. 

That  scarring  may  be  scattered  in  the  bundle  so  that  some 
of  the  fibers  are  spared,  is  illustrated  in  G*.se  xxv.  This 
concerns  a  male,  aged  seventy-five,  who  died  of  heart  block, 
general  arteriosclerosis  and  atheroma  of  the  coronary  arteries. 
Here,  there  was  found  scarring  at  the  origin  of  the  bundle  but 


NEUR0M1  SCULAR  TISSUE  51 

a  number  of  fibers  passed  through  intact.  Evidently  the 
block  n;_r  was  only  in  some  of  the  finer  divisions  of  the  ramus 
septi  fibrosi. 

Additional  a  posteriori  evidence  of  the  existence  ol  a  specific 
bund  e  blood  supply  is  found  in  Case  XXVI.  A  male,  aged 
fifty-seven,  who  showed  at  post-mortem  coronary  arterio- 
sclerosis, chronic  heart  aneurysm,  old  mitral  endocarditis, 
etc.,  presented  an  intact  Ik  .idle  lying  on  an  extensively  and 
thoroughly  scarred  subjacent  and  surrounding  tissue.  Case 
LIX  showed,  similarly,  anemic  necrosis  of  the  septum  with  the 
bundle  inl 

So  far  as  the  effect  of  coronary  arterj  obliteration  on  the 
ultimate  distribution  and  function  of  the  neuromuscular 
structure  is  concerned,  it  can  be  stated  that  the  outlook  is 
much  brighter,  for  though  the  infarctions  show  their  greatest 
extent  on  the  internal  surface  of  the  heart,  the  very  rich  and 
profuse  subendocardial  anastomoses  generally  supply  sufficient 
nourishment  to  the  superimposed  Purkmjc  libers  to  keep 
them  intact. 

Of  course,  where  scarring  has  been  so  extensive  as  to 
involve  the  whole  thickness  of  the  wall  and  include  the  endo- 
cardium, there,  undoubtedly,  disappearance  of  the  Purkinje 
fibers  takes  place,  for  it  is  very  doubtful  whether  the  ventricu- 
lar blood  can  supply  sufficient  nourishment  to  keep  the  sensi- 
tive neuromuscular  tissue  alive.  This  does  not,  however, 
express  itself  necessarily  in  arrhythmias,  since-  there  is  adequate 
and  ample  interanastomosing  of  the  neuromuscular  tissue- 
within  the  chambers  to  supply  and  make  up  for  gaps.  On  the 
other  hand,  it  will  be  shown  in  Chapter  VIII  that  the  nutri- 
tion of  the  innermost  layer  of  heart  wall  varies  considerably  in 
its  supplj    with   the  age  of  the   individual,   becoming   much 


52  THE  BLOOD  SUPPLY  TO  THE  HEART 

richer  and  better  able  to  stand  arterial  obliteration  as  age 
progresses. 

This  has  apparently  been  recognized  to  a  certain  extent 
by  Haas,  for  in  a  ease  which  he  cites,  where  there  was  an 
atheromatous  obliteration  of  the  ramus  septi  ventriculorum 
superior  with  anemic  infarction  of  the  posterior  portion  of  the 
septum  and  adjoining  part  of  the  left  ventricle,  the  subendo- 
cardial musculature  was  intact.  This,  he  explains,  was  due 
cither  to  plentiful  blood  supply  to  this  layer,  or  to  nourishment 
from  the  blood  contents  of  the  ventricle. 

Finally,  Moenckeberg  had  already  concluded  that  variabil- 
ity must  exist  in  the  blood  supply  to  the  heart  and  conse- 
quently in  the  original  source  of  blood  to  the  neuromuscular 
structure,  for  he  observed  that  blockage  of  the  same  part  of  a 
coronary  artery  produced,  in  different  hearts,  different  results 
in  the  bundle.  This  conclusion  is  amply  supported  by  the 
variations  which  are  described  in  Chapter  III. 


Chapter  \ 

The  Blood     Supply-  to  the  Heart  Valves  and 

its  Relation  to  the  Inflammations  of 

the  Valves 

WITH  the  possible  exception  of  the  chapter  dealing 
with  the  existence  of  anastomoses  in  the  heart, 
no  part  ol  cardiac  vascular  morphology  has  been 
the  subject  of  so  much  controversy  as  that  on  the  blood  supply 
to  the  val\  es. 

Apart  from  its  anatomical  interest,  Koster's  acceptance  oi 
the  existence  of  blood-vessels  in  valves  as  a  basis  lor  his  theorj 
of  embolic  endocarditis  has  brought  additional  importance  to 
this  question  and  has  precipitated  two  distinct  schools  of 
thought.  One  of  these  denies  the  existence  of  vessels  in  normal 
valves  and  holds  with  Riihle  that  endocarditis1  is  caused  by 
adhesion  of  bacteria  from  the  main  blood-stream  to  the  valves. 
1  he  selection  ol  the  closing  edge  as  the  usual  primary  seat  ol 
the  lesion  is,  according  to  this  opinion,  due  to  the  fact  that  the 
\al\e  is  here  exposed  to  the  greatest  mechanical  compression 
during  diastole  and  systole,  in  the  case  ol  semilunar  and  auricu- 
[oventricular  valves  respectively.  This,  perhaps,  together  with 
a  greater  phagocj  tic  power  of  the  cells  in  this  locality,  accounts 
for  the  great  frequence  ol  endocarditis  at  this  site.  I  he  other 
school  claims  that  blood-vessels  normally  exist  in  valves  and 
that  bacteria]  emboli  lodge  in  the  site  of  greatest  constriction, 

'  I  In   endocarditis  referred  to  in  this  chapter  is  the  valvulai  variety. 

53 


54  THE  BLOOD  SUPPLY  TO  THE  HEART 

namely,  where  the  delicate  capillary  arborizations  take  place 
at  the  closing  edge;  here,  therefore,  a  septic  focus  with  inflam- 
mation, rapid  involvement  of  the  overlying  endocardium  and 
thrombosis  occurs. 

Luschka  was  the  first  to  claim  that  auriculoventricular  as 
well  as  semilunar  valves  were  vascularized.  He  stated  that  the 
semilunar  valves  receive  their  blood  supply  from  the  vasa 
vasorum  as  well  as  from  the  richly  vascularized  endocardium 
and  that  the  auriculoventricular  valves  receive  their  blood 
supply  from  the  attached  edge  as  well  as  from  the  papillary 
muscles,  through  vessels  which  run  along  the  chordae  tendineae. 
He  described  these  vessels  as  forming  an  arterial  network  in  the 
main  portion  of  the  valve  leaflets,  accompanied  by  veins,  and 
breaking  up  into  more  delicate  strands  which  eventually 
end  as  capillaries  at  the  closing  edge.  He  also  correlated  the 
frequency  of  endocarditis  on  the  aortic  leaflet  of  the  mitral 
valve  with  the  relative  ease  with  which  blood-vessels  can  be 
found  in  this  situation. 

Rokitansky,  Virchow,  Joseph,  and  later  Cadiat  opposed 
these  views,  whereas  Gerlaeh,  Forster,  KoIIiker  and  Rosen- 
stein  confirmed  them. 

A  third  group,  represented  chiefly  by  Sappey,  Frey, 
Henle  and  Coen  arose,  who  stated  that  blood-vessels  exist  in 
the  auriculoventricular  valves,  but  not  in  the  semilunar  cusps. 

Langer  modified  this  view  in  pointing  out  that  blood- 
\tssels  exist  in  those  valves  where  muscle  fiber  remains  are 
to  be  found. 

This  was  followed  a  year  later  by  Darier  whose  conclusions 
are  in  part  as  follows: 

(a)  There  never  exist  any  vessels  in  the  libro-elastic  part  of  the  auriculo- 
\  entricular  valves. 


BLOOD  SUPPLY  TO  THE  HEART  VALVES  55 

•  In  The  valves  of  the  tricuspid  and  the  left  mitral  leaflet  are,  as  a  rule, 
entirely  fibro-elastic;  the  aortic  leaflet  of  the  mitral  valve  presents  vascu- 
lature only  in  its  upper  part,  generally  not  more  than  one-sixth  of  its 
length. 

(c)  In  newborn  children,  one  sees  muscular  bundles  penetrating  more 
or  less  to  the  tore  in  all  auriculoventricular  valves. 

(d)  In  pathological  changes  in  the  valves,  \csscls  are  seen  throughout 
the  entire  extent  of  the  semilunar,  tricuspid  and  mitral  valves. 

(e)  These  vessels  seem  to  be  the  result  of  inflammations. 

(J  )  Those  writers  who  have  succeeded  in  injecting  the  vascular  network 
of  the  aortic  and  mitral  valves  have  obtained  pathological  appearances. 

(g)  The  valvular  hematomata  found  in  the  newborn  appear  coincident 
witli  the  processes  (if  regression  of  vessels  which  occur  in  the  valves  during 
the  letal  period. 

Darier's  conclusions  have  here  been  stated  somewhat  in 
detail,  for  in  the  subsequent  discussion  they  acquire  import- 
ance. 

Odmzow  later  confirmed  the  results  ol  Langer  and  Darier 
and  these  were  again  accepted  by  Koniger. 

Recently,  Nussbanm  has  described  a  tortuous  vasculature, 
which  extends  about  3  mm.  from  the  base  of  the  auriculo- 
ventricular valves  into  the  leaflet,  but  no  farther.  He  was 
unable   to  demonstrate  blood-vessels  in   t  he  semilunar  \alves. 

In  1 1 >  1  Bayne-Jones  injected  14  human  hearts:  6  from 
the  first  decade  of  hie,  2  from  the  second,  2  from  the  third  and 
4  between  the  ages  ol  thirty  and  sixty. 

Out  of  these  14  hearts  he  was  able  to  obtain  a  fairly 
complete  injection  in  3.  In  some  ol  the  others  onl\  irregular 
groups  ol  vessels  were  seen  which  branched  into  delicate 
arteriole's  extending  to  the  line  of  closure  of  the  valves. 

A  description  based  on  the  three  most  completely  injected 
hearts  shows  that  the  mitral  and  tricuspid  valves  receive  a 
distinct  x  asculari/ation  from  delicate  twigs  which  arise  from  t  he 
annular  branches  ol  the  right  and  lelt  coronary  arteries,  and  not 


56  THE  BLOOD  SUPPLY  TO  THE  HEART 

Irom  vessels  extending  from  the  auricular  musculature.  The  blood- 
vessels extend  to  the  line  of  closure,  where  they  form  abundant 
anastomoses.  Only  occasionally  do  small  vessels  pass  from  the 
line  of  closure  to  the  free  edge  of  the  valve. 

In  the  upper  portions  of  the  valves  Bayne- Jones  was  able  to 
demonstrate  veins  which  showed  characteristic  differences  from 
the  arteries. 

The  chordae  tendineae  showed  blood-vessels  which  reached 
almost  to  the  insertion  into  the  valves,  but  never,  in  the  human, 
actually  passed  on  to  the  valve. 

Bayne- Jones  also  succeeded  in  injecting  3  aortic  and  more 
pulmonary  valves.  The  source  of  blood  supply  to  these  corre- 
sponds to  the  description  already  given  by  Luschka.  The  injec- 
tion extended  usually  from  the  base  of  the  cusp  half-way  to  the 
edge.  A  few  tiny  vessels  could  be  seen  at  the  line  of  closure. 

\\  ith  all  this  conflicting  evidence,  therefore,  it  is  not 
strange  that  there  should  be  much  dissension,  and  that  some 
should  claim,  as  does  Darier,  that  blood-vessels  exist  onk 
where  there  has  been  inflammation,  and  others,  that  blood- 
vessels occur  in  perfectly  normal  valves  and  that  the  idea  of 
their  non-existence  is  due  to  the  inability  of  the  observers  to 
demonstrate  them.  Bayne-Jones,  in  fact,  believes  that  technical 
difficulties  account  for  most  of  the  failures.  He  insists  that  the 
heart  must  be  kept  until  rigor  mortis  passes  off;  that  all  cut 
edges  as  well  as  venous  exits  must  be  tied  off;  and  that  injec- 
tion with  a  fine  gelatine  must  be  carried  on  at  a  pressure  of 
from  160-190  mm.  Hg  to  obtain  satisfactory  results. 

It  can  easily  be  seen  that  the  conception  of  the  existence 
of  blood-vessels  in  valves  is  essential  to  the  theory  of  embolic 
endocarditis. 

Finally,  there  is  the  third  group  to  consider,  represented 


THE  BLOOD  SUPPLY  TO  THE  HEART  VALVES       57 

by  Langcr  and  others,  who  claim  that  blood-vessels  occur  in 
those  situations  where  muscular  remains  persist. 

From  the  experiments  carried  on  by  the  author,  as  well  as 
from  a  different  interpretation  of  the  literature  on  this  ques- 
tion, it  seems  that  each  ol  these  conflicting  views  is  correct 
if  taken  in  part,  and  that  they  can  all  be  coordinated  into  a 
logical  and  reasonable  explanation  lor  the  genesis  and  mech- 
anism of  at   least  many  cases  ol"  acute  valvular  endocarditis. 

As  Tandler  states,  since  kiirschner's  description  of  the 
musculature  found  in  the  valves  of  human  hearts,  numerous 
in\  est iga tors  have  followed  with  descriptions  and  studies  ol  the 
frequency  ol  occurrence  of  this  tissue  in  the  valves,  ol  its 
relation  to  the  age  of  the  individual,  and  of  its  source  from  auri- 
cle or  ventricle. 

It  seems  quite  clear  that  the  auricular  musculature  which 
is  quite  abundant  in  fetal  valves,  becomes  less  so  as  the  in- 
dividual <j,rows  older.  In  children,  as  Langcr,  Darier,  Manzone 
and  Odinzow  have  shown,  the  musculature  is  still  relatively 
abundant,  but  with  beginning  adolescence  even  this  disap- 
pears and  eventually,  with  few  exceptions,  the  valve  is  rvn- 
dcrcd  muscle-free.  But  these  exceptions  are  of  prime  interest. 
One  finds  in  these,  bundles  and  columns  of  musculature  which, 
in  some  cases,  are  relatively  abundant  and  still  maintain  their 
original  connection  with  the  auricular  musculature;  in  others, 
exist  as  isolated  delicate  strands. 

Tlie  ventricular  musculature  is  apparently  much  lesv 
important  in  t  his  connection. 

Langer's    painstaking    and    accurate    observations    as    to 

the  coexistence  of  blood-vessels  with  this  musculat  Lire  is 
supported  by  numerous  investigators.  The  fact  that  blood- 
vessels   are   lound    most    easib    towards   the   base  of  the   valve 


,-8  THE  BLOOD  SUPPLY  TO  THE  HEART 

where  the  main  mass  of  musculature  exists,  has  been  amply 
corroborated    recently    by    Nussbaum    and    by    the    author. 

The  blood-vessels,  moreover,  become  obliterated,  lose 
their  continuity  with  their  main  source  (vessels  which  arise 
from  the  ramus  circumflexus  sinister  and  dexter  as  well  as 
from  the  superior  rami  interventriculares),  become  blood- 
containing  spaces  (which  perhaps  accounts  for  the  valvular 
hematomata  so  frequently  found  at  birth)  and  eventually 
disappear. 

This  regression  of  blood-vessels  proceeds  hand  in  hand 
with  the  regression  of  the  musculature;  in  fact,  as  Odinzow  has 
pointed  out,  the  musculature  may  entirely  disappear  before  the 
vessels.  In  children  where  the  muscular  regression  is  incomplete, 
blood-vessels  frequently  persist. 

If  the  literature  on  the  mechanism  of  acute  valvular 
endocarditis  is  now  reviewed  in  this  light,  one  is  at  once 
struck  with  the  fact  that  the  occurrence  of  endocarditis  bears 
a  strikingly  close  relationship  to  that  of  the  existence  of 
musculature  and  of  blood-vessels  in  valves.  This  becomes 
even  more  striking  when  the  incidence  of  endocarditis  is 
considered  from  the  point  ot  view  of  the  frequency  with  which 
it  occurs  on  the  left  and  right  sides  as  well  as  on  the  individual 
valves  and  cusps. 

In  the  fetus,  where  the  valves,  in  keeping  with  the  muscula- 
ture, arc  undoubtedly  better  vascularized  on  the  right  side  of 
the  heart,  endocarditis  is  much  more  frequently  found  on  the 
right  side  than  on  the  left. 

In  children,  where  the  complete  regression  of  vasculature 
has    not    yet    occurred,    endocarditis    is    relatively    frequent. 

Finally,  in  adults,  the  most  frequent  seat  of  endocarditis 
is  the  aortic  cusp  of  the  mitral  valve,  the  very  leaflet  which 


Fig.  g. — Photograph  of  injected  specimen,  showing  the  blood  supply  to  the 
aortic  cusp  of  the  mitral  valve  which  is  the  seat  of  an  acute  endocarditis. 


59 


Fig.  io. — Photograph  of  the  tricuspid  valve  from  the  same  heart  as  in  Fig.  9. 


61 


Fu;.   ii.    -Photograph  of  the  pulmonarj  valve  from  the  same  heart  as  in  I  ig.  9. 


63 


Fig.   12. — Photograph  ol  the  aortic  valve  from  the  same  heart  as  in  1    _    9, 
showing  the  blood  supplj  to  the  cusps. 


65 


THE  BLOOD  SUPPLY  TO  THE  HEART  VALVES      67 

Langer  has  already  shown  to  be  the  last  to  lose  its  musculature, 
and  which,  as  so  many  observers  have  found  and  the  author's 
injections  have  entirely  corroborated,  is  the  most  usual  site  of 
complete  injection. 

That  practically  all  cases  of  acute  valvular  endocarditis 
show  a  well-developed  vasculature  seems  certain.  The  author 
has  not  yet  failed  to  demonstrate  it  in  such  cases.  These 
\  essels  cannot  be,  as  Darier  claimed,  entirely  secondary  to  the 
inflammation,  for  they  are  quite  orderly  in  arrangement, 
possess  veins  and  bear  no  resemblance  to  granulation  tissue. 
Moreover,  their  capillary  terminations  extend  to  the  closing 
edge  of  the  valve  when  this  is  the  seat  of  the  lesion;  and  it  is 
rather  forced  to  assume  that  granulation  tissue  extends  through 
the  whole  of  so  large  a  valve  as  the  aortic  leaflet  of  the  mitral, 
to  the  terminal  edge  in  order  to  supply  the  seat  of  bacterial 
adhesions  with  a  well-organized  vasculature. 

Figure  0  shows  a  typical  injection  from  such  a  case.  It  will 
be  seen  that  several  delicate  vessels  descend  from  the  insertion 
of  the  aortic  cusp  of  the  mitral  valve  at  its  base.  The  most 
anterior  of  these  twigs  arise  from  the  first  portion  of  the 
ramus  circurriflexus  sinister;  the  posterior  branches,  from  the 
uppermost  rami  interventrieulares.  Descending  to  about  tin 
middle  of  the  leaflet,  they  anastomose  in  tin-  form  of  an  arch, 
from  the  convex  border  of  which  numerous  interlacing  and 
interanastomosing  arborizations  are  given  oil.  (This  is  even 
better  seen  in  the  cleared  specimen.)  Towards  the  closing 
edge  of  the  valve,  where  the  fungoid  vegetative  lesion  is  seen,  a 
final  capillary  breaking-up  occurs  to  supply  richly  this  site. 

The  posterior  cusp  of  the  mitral  valve  shows  no  vasculariza- 
tion but  is  the  seat  of  apparently  more  recent  thrombotic 
vegetations  which  extend  up  the  wall  of  the  left  auricle. 


68  THE  BLOOD  SUPPLY  TO  THE  HEART 

The  tricuspid  (Fig.  10)  as  well  as  the  pulmonary  valve 
(Fig.  11)  are  free  from  endocarditis  and  show  no  vasculature. 
The  aortic  valve,  however,  shows  in  all  three  cusps,  vessels 
which  extend  from  the  base  to  the  middle  (Fig.  12).  In  this 
connection,  it  is  very  interesting  to  find  that,  in  this  specimen, 
the  aortic  valve,  which  is  so  frequently  the  seat  of  an  endo- 
carditis following  a  mitral  lesion,  should  show  a  vasculature, 
and  one  wonders  whether,  if  this  patient  had  lived  long  enough, 
an  endocarditis  would  not  have  occurred  here.' 

Normal  valves  can  certainly  be  injected,  but  only  excep- 
tionally. The  author  has  succeeded  in  injecting  the  mitral 
valve  in  about  6  per  cent  of  normal  hearts  which,  however, 
represented  all  age  periods  from  birth  to  the  ninth  decade  of 
life.  Figure  13  shows  such  an  injection;  in  this  case  only  the 
aortic  leaflet  of  the  mitral  valve  showed  vasculature.  The 
course  of  the  vessels  is  very  much  the  same  as  that  found  in 
the  case  of  endocarditis. 

When  a  complete  injection  of  all  the  valves  is  obtained,  it  is 
found  that  the  posterior  cusp  of  the  mitral  receives  its  blood 
from  the  terminal  portions  of  the  ramus  circumflexus  sinister 
and  dexter,  and  that  the  tricuspid  valve  receives  its  blood  from 
the  ramus  circumflexus  dexter  as  well  as  from  the  superior 
rami  interventriculares,  according  to  the  position  of  the  leaflets. 
Where  the  ramus  circumflexus  sinister  extends  beyond  the 
crux,  the  posterior  leaflets  of  the  mitral  and  tricuspid  valves 
receive  their  blood  from  this  vessel. 

The  frequency  with  which  these  valves  can  be  injected 
depends  upon  the  age  of  the  individual.  It  will  be  observed 
that  out  of  the  14  carefully  selected  human  hearts  which 
Bayne-Jones  injected,  10  belonged  to  the  first  thirty  years  of 
life,  and  of  these  again  6  were  from  the  first  decade;  in  spite  of 


Fig.   13.   -Photograph  of  injected  specimen,  showing  the  blood  supply  to 
the  aortic  leaflet  of  a  normal  mitral  valve. 


69 


THE  BLOOD  SUPPLY  TO  THE  HEART  VALVES       71 

this,  he  was  able  to  inject  fairly  completely,  only  3  eases.  It  is 
the  author's  belief  that  the  other  eases  could  not  be  injected 
because  vessels  did  not  exist.  In  fact,  the  frequency  with  which 
he  succeeded  in  these  cases  is  due  to  the  fact  that  in  young 
hearts,  where  muscular  remains  still  occur  fairly  frequently,  the 
vasculature  is  persistent  in  the  same  ratio. 

In  the  hearts  which  the  author  injected,  every  possible 
precaution  was  taken  to  eliminate  artefact  and  to  ensure  a 
perfectly  standardized  injection.  Each  heart  was  subjected 
identically  to  the  same  procedure  as  described  in  Chapter  I.  In 
spite  of  this,  only  about  6  per  cent  of  the  hearts  showed  valvu- 
lar injection,  and  of  these,  the  aortic  cusp  of  the  mitral  valve 
was  the  most  frequent  seat. 

Dr.  M.  Notkin  examined  in  our  laboratories  microscopi- 
cally and  in  serial  section  the  valves  which  showed  no  injec- 
tion and  was  unable  to  demonstrate  in  them  any  blood-vessels 
or  capillaries,  thus  substantiating  the  conclusion  that  these 
valves  showed  no  injection  because  vessels  were  non-existent. 

If  the  foregoing  facts  arc  now  arranged  in  orderly  form,  one 
ma\   begin  with  the  following  premises: 

1.  Fetal  valves  contain  musculature  on  right  and  [eft 
sides,  the  right  probably  being  richer  in  blood-vessels. 

2.  Fetal  valvular  endocarditis  is  found  more  frequently 
on  the  right  side. 

3.  Regression  of  musculature  and  blood-vessels  occurs  as 
age  advances,  but  infant's  valves  still  frequently  contain  both. 

4.  Infants  are  frequently  attacked  by  valvular  endocarditis. 

5.  In  adults,  valvular  endocarditis  is  not  as  frequent  as  m 
children  but  occurs  with  preference  on  the  aortic  cusp  <>l  the 
mitral  valve. 

6.  The  aortic  cusp  of  the  mitral  valve  is  the  last   to  show 


-2  THE  BLOOD  SUPPLY  TO  THE  HEART 

regression  of   musculature  and  the  most   frequently   injected 
leaf. 

7.  Practically  all  cases  of  valvular  endocarditis  show  a 
distinct  vasculature. 

8.  Relatively  few  normal  heart  valves  show  in  the  adult  a 
vasculature,  the  frequency  being  somewhat  greater  than  the 
occurrence  of  persistent  muscular  strands. 

To  these  may  be  added: 

9.  Hearts  which  show  congenital  anomalies,  arrests  in 
development,  very  frequently  show  also  an  endocarditis,  and 
this,  moreover,  is  more  frequently  the  case  on  that  side  and  at 
that  location  where  the  arrest  of  development  is  seen,  particu- 
larly where  this  bears  a  close  association  with  interference 
with  the  embryonic  valve  anlage.  In  such  cases  one  would 
expect  perversions  and  arrests  of  normal  vascular  regression  on 
the  same  side. 

This  view   is  lent  considerable  support  by  a  study,  very 

kindly  made  for  the  author  by  Dr.  Maude  E.  Abbott,  on  the 

incidence    of   acute    endocarditis    in    581    congenital    cardiac 

defects.  The  following  is  a  short  excerpt  in  table  form  from 

these  cases: 

Number  Acute 

nj  Cases      Endocarditis 
Anomalous  Septa 

In  left  auricle 7  o 

In  right  auricle 3  1 

In  ventricles 2  o 

Dejects  of  Auricular  Septum 

Patent  foramen  ovale 

High  auricular  septal  defect 

Low  auricular  septal  defect 

Defects  of  Interventricular  Septum 

Defects  at  base 

Defects  elsewhere  than  at  base 


19 

0 

9 

0 

12 

4 

34 

9 

3 

0 

THE  BLOOD  SUPPLY  TO  THE  HEART  VALVES       73 

(The  four  cases  of  acute  endocarditis  occurring  in  the  low  auricular 
septal  defects  with  persistent  ostium  primum  and  consequent  cleavage 
of  the  anterior  segment  of  the  mitral  valve,  presented  vegetations  on  the 
valves  of  the  left  siclc.i   In  this  group,  the  close  relationship  between  the 

occurrence  of  acute  endocarditis  and  delects  which  involve  the  reg I 

the  auriculoventricular  valve  anlage,  is  of  considerable  significance. 


Number  Acute 
oj  Cases  '   Endocarditis 

Cor  Biloculare  and  Triloculare.            23  o 

Deject  itf  Aortic  Septum 

Complete  defect  (persistent  truncus) 13  o 

Partial  delect   (with  defect  ol  ventricular 

septum  '    1  1 

lieu-  it  is  found  that  a  complete  absence  ol  septum  formation  is  nut 
associated  with  the  occurrence  >>l  acute  endocarditis.  In  the  cases,  how- 
ever, where  there  was  an  aborted  attempt  at  this  formation,  endocarditis 

was  found. 

Number  Acute 

of  ('uses  Endocarditis 

Pulmonary  Stenosis                                                        82  21 

Pulmonary  Atresia.                                                      24  1 

Subaortic  Stenosis.                                    8  3  (on  left 

side) 

Aortic  Stenosis 6  o 

Aortic  Atn  sia                           3  o 

Tricuspid  Stenosis 2  o 

Tricuspid  Atresia.                                                           10  2 

Mitral  Stenosis .  .  .  .  .                                        1  0 

Mitral  Atresia 3  o 

Anomalies  oj  Auriculoventricular  Valves 12  0 

Although  not  so  suggestive,  these  figures  indicate  the  importance  ol 

defects     which    produce    stenosis,    in    connection    with    endocarditis,    and 
emphasize  the  frequencj    with  which  this  occurrence  is  on  the  right   side. 

Other  cases  are  considered  which,  though  not  so  pertinent 
to  this  question,  indicate,  nevertheless,  that  the  anatomical 
factor  ol  narrowing  vasculature,  which  maj  indeed  l)e  second- 


-4  THE  BLOOD  SUPPLY  TO  THE  HEART 

ary  to  a  wear-and-tear  scarring  process,  is  intimately  asso- 
ciated with  the  occurrence  of  endocarditis. 

It  would  appear  from  these  premises  that  only  a  certain 
percentage  of  postnatal  hearts  contain  persistent  fetal  vas- 
culature of  valves  and  that  valvular  endocarditis  may  be 
caused  by  embolization  of  bacteria  in  these  persistent  vessels. 
But  as  this  persistence  is,  fortunately,  relatively  infrequent, 
it  follows  that  the  incidence  of  valvular  endocarditis,  resulting 
from  an  embolizing  bacteremia  due  to  organisms  which  are 
causative  agents  of  this  disease,  will  bear  a  relation  to  the 
frequency  with  which  blood-vessels  are  found  in  the  valves. 
It  would,  therefore,  be  important  to  obtain  figures  of  this 
incidence  at  different  age  periods  in  relation  to  the  occurrence 
of  blood-vessels  in  the  valves.  This  figure,  it  is  believed,  would 
probably  represent  very  closely  the  proportion  of  cases  of 
endocarditis. 

Just  as  an  individual  in  whom  other  fetal  structures 
persist,  is  exposed  to  the  possibility  of  their  disease,  so,  it  is 
the  author's  opinion,  the  individual,  whose  valvular  vascu- 
lature has  not  undergone  regression,  is  liable  or  predisposed 
to  a  valvular  endocarditis. 

If  endocarditis  were  caused  only  by  bacterial  adhesions 
to  the  closing  edge  of  a  valve  where  compression  is  greatest, 
it  does  not  seem  quite  clear  why  the  aortic  cusp  of  the  mitral 
valve  should  be  the  most  frequent  to  suffer.  Nevertheless, 
it  is  not  the  author's  intention  to  deny  the  possibility  of 
valvular  infection  by  way  of  the  main  blood-stream,  as  indeed 
it  seems  to  occur  in  parietal  endocarditis  (toxic  form  as  shown 
by  de  Vecchi,  or  bacterial  form,  by  Ribbert),  but  it  appears 
desirable  to  emphasize  that  in  view  of  the  considerations  pre- 
sented  above,    it   is    probable    that    an    individual  who    has 


THE  BLOOD  SUPPLY  TO  THE  HEART  VALVES      75 

persistent  valvular  blood-vessels  is  certainly  additionally 
exposed  to  endocarditis.  Here  the  compression  at  the  edges 
would  serve  as  still  another  factor,  besides  the  narrowing  of  the 
blood-stream,  for  precipitation  of  bacterial  clumps. 

Tlie  heart  valves  are  peculiar  in  that  they  are  the  only 
structures  in  the  body  which  undergo  periodic  compressions 
by  a  force  equal  to  the  weight  of  approximately  100  mm.  Hg 
and  over.  Moreover,  these  compressions,  according  to 
Howell,  occur  seventy  times  a  minute  and  last  0.379  second 
in  the  case  of  auriculoventricular  valves,  and  0.483  second  in 
the  case  of  semilunar  valves.  In  other  words,  the  capillaries  in 
the  edges  of  the  auriculoventricular  valves  are  compressed 
for  10.612  hours  during  the  day,  and  those  of  the  semilunar 
valves,  13.524  hours.  This  would  afford  an  excellent  oppor- 
tunity for  the  arrest  and  development  of  pathogenic  bacteria. 

It  may  be  argued  that  the  incidence  of  endocarditis  in 
certain  infections,  such  as  rheumatic  lexer,  is  so  common  that 
the  relative  infrequency  oi  persistent  vasculature  in  valves  is 
here  of  little  importance.  But  this  objection  loses  much  weight 
in  the  light  of  stricter  criticism,  for  hospital  statistics  are 
no  indication  of  the  relative  proportion  of  the  occurrence  of 
endocarditis  in  rheumatic  lexer.  Moreover,  Osier's  statement 
and  general  clinical  experience,  that  the  insusceptibility  to  en- 
docarditis diminishes  as  age  advances,  are  stronglj  suggestive 
of  the  influence  of  age  on  the  regressive  anatomical  changes  in 
tin  valvular  vasculature. 

It  must  also  be  borne  in  mind  that  other  factors  besides 
the  mechanical  may  enter  into  the  occurrence  of  an  endo- 
carditis; for,  whereas  certain  bacteria  max  require  compression 
lor  settlement  and  action  at  the  closing  edge  of  a  valve, 
other,    perhaps    more    virulent,    organisms    max     be    enabled 


76  THE  BLOOD  SUPPLY  TO  THE  HEART 

to  localize  and  set  up  inflammation  in  a  part  of  a  vessel 
not  submitted  to  this  mechanism.  Thus,  ulcerative  endo- 
carditis is  known  to  arise  relatively  frequently  in  other  por- 
tions of  the  endocardium  and  in  the  valve  leaflet.  Here,  the 
fact  that  occasionally  the  valvular  vessels  terminate  before 
reaching  the  edge,  may  serve  as  a  focus  of  bacterial  arrest. 
This  was  well  illustrated  in  several  typical  cases  recently 
injected  by  the  author. 

Finally,  through  lack  of  sufficient  material  the  author 
unfortunately  cannot  give  accurate  statistics  from  his  own 
observations  on  the  frequency  with  which  valves  can  be 
injected  during  the  different  age  periods,  but  it  would  be  of 
great  importance  to  obtain  exact  information  in  regard  to 
the  percentage  of  successful  injections  in  increasing  age,  for  it 
appears  probable  that  the  latter  would  be  accompanied  by  a 
decreasing  percentage. 

Those  who  have  attempted  to  inject  blood-vessels  in 
valves  have,  therefore,  failed  in  a  great  many  instances, 
not  only  on  account  of  an  imperfect  technique,  but  doubtless 
also  because  of  the  normal  evolution  of  heart  valves  which  in 
adult  life  usually  causes  a  complete  disappearance  of  vessels. 


Chapter  VI 
The  Anastomoses  Between  the  Coronary  Arteries 

EVEN  though  the  question  as  to  the  existence  of  anas- 
tomoses between  the  coronary  arteries  has  been  the 
subject  of  long  controversy  and  discussion,  it  can  now 
with  certaintv  be  stated  that,  to  this  at  least,  a  final  answer 
has  been  given. 

The  question  of  anastomoses  resolves  itself  into  three 
gn  nips: 

(i)  Do  anastomosis  exist  between  the  right  and  left 
coronary  arteries  both  in  their  capillary  and  precapillary 
distribution? 

:     Do     anastomoses     exist     between     branches     of    each 
coronary  artery? 

13)  Do  anastomoses  exist  between  the  coronary  arteries 
and  \essels  of  the  adjacent  and  attached  organs? 

The  sources  of  information  on  these  questions  have  been 
extraordinary  both  in  the  number  of  contributors  and  investi- 
gators, as  well  as  in  the  methods  employed  for  its  elucidation. 
The  following  classification  shows  how  varied  were  the 
factors  which  the  different  observers  employed  singly  and  in 
combination  in  these  investigations: 
a)   Dissection. 

Experimental  tying-off  of  coronary  arteries  or  their 
branches,  ehiclb  in  dogs,  to  determine,  by  evidence  of  infarct 
formation  or  rapidity  with  which  heart  stoppage  occurred,  the 
existence  or  non-existence  of  anastomoses. 


78  THE  BLOOD  SUPPLY  TO  THE  HEART 

(c)  Injection  of  colored  gelatines  into  both  arteries. 

(d)  Injections  of  a  colored  gelatine  into  one  coronary 
artery  to  see  whether  it  passes  out  of  the  other. 

(e)  Serial  section  and  reconstruction  of  injected  specimens. 
(/)  Injection  of  metals  with  subsequent  corrosion. 

(g)  Injection  of  gelatine  suspensions  of  heavy  salts  with 
subsequent  roentgenography. 

(h)  Injection  of  colored  gelatines  with  clearing  of  the 
remaining  tissue. 

( i )  Examination  and  dissection  of  pathological  specimens 
showing  obliteration  of  branches. 

(/')  Observation  of  clinical  cases  with,  frequently,  autopsy 
examinations. 

To  these,  the  author  has  added: 

(k)  Injection  of  vessels  with  a  gelatine  suspension  of  a 
heavy  salt  by  a  special  technique  which  standardizes  all 
mechanical  factors.  This  is  followed  by  stereoscopic  roentgen- 
ography of  the  organ,  clearing,  dissection  and  microscopic 
section.  Normal  as  well  as  pathological  hearts  were  used  for  the 
purpose.  (See  Chapter  I.) 

The  first  historical  experiments  on  the  effect  of  tying-off 
a  coronary  artery  in  a  dog  were  those  made  by  Chirac  in  1698. 
These,  however,  threw  no  light  on  the  question  of  anastomoses, 
since  the  only  observation  made  by  him  was  that  the  heart 
ceased  beating. 

It  was  not  until  1708  that  Thebesius,  followed  later  by 
Haller,  Morgagni  and  Senac,  on  the  basis  of  careful  dissections, 
came  to  the  conclusion  that  anastomoses  exist  between  both 
coronary  arteries.  Haller  stated  that  these  were  quite  rich  and 
occurred  with  frequency  at  the  root  of  the  pulmonary  artery, 
in  the  posterior  sulcus  Iongitudinalis,   in  the  right  ventricle, 


ANASTOMOSES  BETWEEN  CORONARY  ARTERIES  -9 

at  the  apex  of  the  heart,  on  the  surface  of  the  ventricles  and 
through  the  vasa  vasorum  of  the  great  vessels. 

In  [799  Parry  and  Jenner  (cited  by  Parry)  first  interpreted 
the  clinical  syndrome  known  as  angina  pectoris  as  due  to  cal- 
cification  of  the  coronary  arteries  and  the  autopsy  findings  on 
John  Hunter's  heart,  after  Jenner  had  diagnosed  his  condition, 
corroborated  this  vievt . 

In  1810  Caldani's  dissections  revived  the  claim  that  anas- 
tomoses exist,  particularly  at  the  root  of  the  pulmonary 
artery.  Cruveilhier  again  described  wide  anastomoses  between 
both    coronarj    arteries   as   well    as    with    bronchial    arteries. 

In  1842  Erichsen  published  his  results  of  experimental 
ligature  ol  coronaries  in  animals  and  concluded  that  "any 
circumstance  that  may  interfere  with  passage  of  blood  through 
the  coronary  arteries  either  directly,  as  in  ossification  of  the 
coats  of  those  vessels,  or  indirectly,  by  there  not  being  sufficient 
blood  sent  out  of  the  left  ventricle  as  in  cases  of  extreme 
obstruction  or  regurgitant  disease  of  the  aortic  or  mitral  valve, 
may  occasion  the  fatal  event." 

In  [855  HyrtI,  on  the  basis  of  injection  and  corrosion 
experiments,  categorically  denied  the  existence  of  anastomosis 
between  the  coronary  arteries  and  this  was  confirmed  in  1866 
by  Ilenle,  who  stated,  however,  that  capillary  anastomoses  do 
occur. 

Krause  was  the  first  to  oppose  the  views  of  HyrtI,  but 
meanwhile  Beraud  had  found  that  anastomoses  exist  between 
the  coronary   arteries  and  vessels  from  adjoining  organs. 

Pamfm,  von  Bezold  and  Brevmann  and  later  Samuelson 
again  experimented  with  dogs  and  were  able  to  confirm  Erich- 
sen's  conclusions. 

In    [880   Langer   showed    that    anastomoses   exist    between 


80  THE  BLOOD  SUPPLY  TO  THE  HEART 

the  coronary  arteries  and  those  of  the  pericardium  and,  through 
these,  with  the  arteriae  mammariae  internae.  He  showed 
further  that  by  means  of  the  vasa  vasorum  of  the  pulmonary 
artery,  connection  also  takes  place  with  the  bronchial  arteries 
and,  through  branches  from  the  auricles,  with  the  diaphragm. 

In  1881  Cohnheim  and  A.  von  Schulthess-Reehberg 
reported  their  experiments  on  the  clamping  of  coronary  arteries 
in  curarizcd  dogs.  Their  conclusions,  which  profoundly  in- 
fluenced the  opinion  of  future  observers  and  which  are  still 
being  held  by  some,  were,  that  clamping  of  either  mam  coro- 
nary artery  caused  the  ventricles  to  stop  in  diastole  within 
two  minutes.  They  accordingly  argued  that  the  coronaries 
were  end-arteries,  and  that,  if  any  anastomoses  exist,  they 
must  consist  of  fine  capillaries. 

This  was  later  confirmed  by  G.  See,  Bochefontaine  and 
Roussy,  Bettelheim  and  Kronecker.  The  ligature  experiments 
thus  far  made,  together  with  injections  carried  out  by  DragnefF, 
Zimmerl  and  Banchi  which  again  confirmed  Hyrtl's  work, 
helped  to  lend  much  support  to  the  opposers  of  the  view  that 
anastomoses  exist. 

It  was  not  long,  however,  before  a  great  many  observers, 
notably  McWilliam,  Fenoglio  and  Droguell,  Bickel,  Roister, 
Tigerstedt,  von  Frey  and  Porter,  after  performing  very  care- 
fully numerous  ligation  experiments  in  dogs,  came  to 
conclusions  opposed  to  those  of  Cohnheim  and  von  Schulthess- 
Reehberg.  In  general,  they  held  that  many  of  the  Iatter's 
results  were  due  to  the  trauma  of  the  operation,  and  that 
tying-ofl  branches  and  even  a  main  coronary  artery  does 
not  necessarily  lead  to  instantaneous  death.  In  i8<)2  Roister 
gave  an  accurate  description  of  the  processes  of  infarct  forma- 
tion and  healing  by  scarring. 


THE  CORONARY  ARTERIES  81 

This  opposition,  moreover,  further  gained  strength  by  the 
collection  and  description  <>l  numerous  clinical  cases  and 
pathological  material  by  Samuelson,  Huber,  Aschofl  and 
Tawara,  Huchard,  West,  Chiari,  Pagenstecher,  Engclhardt, 
Thorel,  Dock,  Galli,  Merkel,  Osier,  Krehl  and,  recently, 
Herrick.  These  observers  were  able  to  show  that  in  the  human 
heart,  obliteration  of  coronary  branches,  and  in  some  cases  a 
main  coronary  artery,  produced  results  which  varied  in  the 
different  cases  from  almost  instantaneous  death  to  those  which 
experienced  no  symptoms  and  showed  absolutely  no  clinical 
sign,  the  condition  being  recognized  only  at  post-mortem 
examination  following  death  from  some  intercurrent  disease. 
Some  of  these  observers,  too,  were  able  to  make  out  by  dis- 
sections distinct  anastomoses. 

It  now  remained  to  describe  exactly  the  location  and 
appearance  of  these  anastomoses  and  to  explain  why,  il 
anastomoses  exist,  infarcts  occur. 

In  1907  Jamin  and  Merkel  elaborated  and  improved  on 
Freyctt's  method  of  radiographing  injected  coronary  arteries 
and  presented  a  stereoscopic  radiographic  study  of  29  hearts 
whose  coronary  arteries  were  injected  with  a  10  to  15  per  cent 
suspension  of  red  lead  in  gelatine.  They  concluded  that  great 
individual  differences  exist  in  the  anastomoses  and  that  these 
are  found  most  frequently  in  the  auricle,  interauricular  and 
interventricular  septum  and,  in  special  instances,  on  the 
anterior  wall  ol  the  right  ventricle,  oxer  the  papillary  muscles 
and  the  ape.x  of  the  heart.  In  pathological  specimens,  the 
anastomoses  wire  found  especially  in  the  interventricular 
septum  and  the  anterior  wall  of  the  left  ventricle. 

In  tin'  same  year  Spaltchol/  employed  a  chromc-\  ellow 
suspension  in  gelatine  for  injections  with  subsequent  dclndra- 


82  THE  BLOOD  SUPPLY  TO  THE  HEART 

tion  and  clearing  in  benzol  and  carbon  disulphide.  By  this 
method  he  was  able  to  obtain  a  reconstruction  of  the  cardiac 
circulation  which,  on  the  whole,  was  vastly  superior  to  any- 
thing hitherto  obtained. 

Spalteholz's  conclusions  are  as  follows: 

(a)  No  end-arteries  exist  in  the  heart. 

(b)  Rich  anastomoses  occur  in  all  layers  of  the  heart  and,  through 
the  vasa  vasorum,  on  the  great  vessels. 

(c)  In  the  thick  muscle  of  the  [eft  ventricle,  perpendicular  vessels 
penetrate  to  anastomose  under  the  endocardium. 

(d)  The  papillary  muscles  are  particularly  rich  in  anastomoses. 

(e)  With  growth,  the  appearance  of  vessels  on  the  surface  show  a 
typical  alteration. 

I  lit  sch  performed  a  series  of  experiments  on  dogs  in  which 
he  tied  off  the  ramus  descendens  anterior  and  observed  in- 
farct formation.  In  all  normal  cases,  however,  he  found  that 
the  infarcted  region  was  much  smaller  than  the  area  of  supply 
of  the  tied-oll  vessel.  In  one  instance  where  the  animal  had 
previously  lost  much  blood,  the  infarcted  area  corresponded 
with  the  entire  musculature  supplied  by  the  vessel.  A  similar 
observation  had  already  been  made  on  the  human  heart  by 
von  Recklinghausen  and  Fujinami. 

In  1909  Miller  and  Matthews  were  able  to  prove  that  many 
of  the  fatal  results  obtained  by  Cohnheim,  Fenoglio  and 
Droguell,  Porter,  etc.,  were  due  to  the  usage  of  curare  and 
morphia.  By  using  ether  as  an  anesthetic  and  employing 
strophanthus  as  a  heart  tonic,  they  obtained  a  mortality  of 
only  8.7  per  cent  after  ligation  of  the  ramus  descendens 
anterior  of  the  left  coronary  artery.  Even  after  tying  off  a 
main  branch  of  the  ramus  descendens  anterior,  the  animal 
would  recover  for  a  period  varying  from  one  to  three  months 
and    ultimately  die  of  acute  cardiac  decompensation.   They 


THE  CORONARY  ARTERIES  83 

were,  therefore,  of  the  opinion  that  considerable  anastomoses 
exist  between  both  coronary  arteries. 

In  1910  Amenomiya  made  a  study  of  the  blood  supply  to 
the  papillary  muscle  and  found  only  capillary  anastomoses. 

In  1911  Nussbaum  described  direct  connections  between 
arteries  and  veins,  made  up  of  a  single  layer  of  endothelium 
possessing  no  muscular  coats  and  lying  in  the  subendocardium. 
He  considered  these  as  safety  outlets  for  arterial  blood  when 
the  pressure  becomes  too  high. 

In  Herrick's  clinical  classification  of  angina  pectoris 
I  1012)  one  group  of  cases  concerns  patients  who  survived  an 
obliteration  of  a  coronary  artery  lor  a  period  ol  time  which 
varied  from  days  to  weeks.  All  these  occurred  in  individuals 
over  fifty  years  of  age.  He  was  of  the  opinion  that  anastomoses 
exist  and  that  the  condition  of  the  heart  musculature  and 
patency  of  the  vessels  played  an  important  part  in  determining 
the  degree  of  compensation  which  can  take  place  after  obliter- 
ation. Gradual  obliteration,  he  argued,  allows  the  heart  to 
adapt  itself  to  the  new  conditions  and  allows  collaterals  to 
develop  sufficiently  to  compensate.  He  suggested  that  the 
\essels  of  Thebesius  might  serve  as  accessory  nutritive  chan- 
nels in  such  cases. 

Finally,  very  recently  Smith  made  an  experimental  study 
on  the  question  as  to  the  existence  of  anastomoses.  By  observa- 
tion on  dogs,  as  well  as  interpretations  of  human  material,  he 
concluded   lor  the   following  reasons  that  anastomoses    exist: 

(a)  Survival  of  dogs  even  after  tying-off  a  relatively  large  vessel. 

(b)  Variability  of  the  lesion. 

ic)   Relatively  small  size  of  the  lesion. 

Thus,  it  cannot  any  longer  be  doubted  that  anastomoses 
exist  between  the  branches  of  an  individual  coronarj  artery  as 


84  THE  BLOOD  SUPPLY  TO  THE  HEART 

well  as  between  branches  from  both  sides.  The  dissections  of 
Thebesius,  Haller,  Morgagni,  de  Senac  and  Caldani,  the  experi- 
mental work  by  McWilliam,  Fenoglio  and  Droguell,  Bickel, 
Kolster,  Samuelson,  Tigerstedt,  von  Frey,  Porter,  Miller 
and  Matthews  and  Smith ;  the  clinical  and  anatomical  obser- 
vations made  by  Samuelson,  Huber,  Aschoff  and  Tawara, 
Huchard,  West,  Chiari,  Pagenstecher,  Engelhardt,  Thorel, 
Dock,  Galli,  Merkel,  Osier,  Krehl  and  Herrick,  as  well  as  the 
injection  work  of  Jamin  and  Merkel,  Spalteholz  and  Nussbaum 
have  placed  this  conclusion  beyond  dispute. 

There  is  still,  however,  no  accurate  knowledge  of  the  exact 
nature  as  well  as  architectural  arrangement  of  these  anasto- 
moses. The  author  has  accordingly  made  a  very  careful  study 
of  this  question  by  the  methods  described  in  the  chapter  on 
technique  and  has  come  to  the  general  conclusion  that  the 
heart  is  perhaps  the  richest  organ  in  the  body  as  regards 
capillary  and  precapillary  anastomoses  between  branches 
of  the  same  coronary  artery  as  well  as  between  branches  from 
both  coronaries.  The  detailed  architectural  description  has 
been  left  to  this  chapter  since  it  represents  a  category  in  itself. 

Figure  24  shows  a  photograph  of  an  injected  and  cleared 
specimen  which  illustrates  beyond  any  dispute  the  abundant 
network  of  anastomoses  at  the  root  of  the  pulmonary  artery. 
A  constant  arterial  arch  is  found  crossing  the  first  part  of  the 
root.  It  corresponds  to  the  venous  arch  seen  in  this  locality. 
The  first  part  of  the  aorta  shows  similarly  extensive  anasto- 
moses between  the  vasa  vasorum  which  arise  from  each  coronary 
artery. 

On  the  surface  of  the  heart  (Figs.  14  and  14  A)  agood  injec- 
tion will  show  a  very  open  anastomosis  occurring  between 
branches  from  the  ramus  descendens  anterior  of  the  left  coro- 


THE  CORONARY  ARTERIES  85 

narv  artery  and  those-  from  the  rami  anteriores  oi  the  right.  A 

similar,  though  usually  less  conspicuous,  anastomosis  occurs  on 
the  corresponding  posterior  surface  between  the  rami  marginis 
obtusi  and  the  rami  ventriculares  sinistn  posteriores  oi  the 
right  coronary  artery. 

The  interauricular  and  particularly  the  interventricular 
septum  is  the  seat  of  very  extensive  and,  in  certain  age  periods 
(Chapter  VI II),  very  wide  anastomoses. 

So  far  as  communication  between  smaller  vessels  ol  the 
heart  is  concerned,  the  auricular  walls  and  appendages,  as  well 
as  the  ventricular  walls  throughout,  are  the  scat  ol  \er\ 
abundant  anastomoses  and  interanastomoses  between  branches 
from  both  coronaries  as  well  as  between  branches  from  each 
coronary  artery.  To  this  may  also  be  added  the  anastomoses 
which  occur  between  the  vessels  which  supply  (when  this 
occurs)  the  valve  leaflets  (Fig.  13). 

Figure  5  shows  the  \cr\  complex  and  complete  anastomosis 
of  small  \csscls,  which  takes  place  beneath  the  endocardium  ol 
the  ventricular  walls  and  papillar  muscles  and  within  the 
musculature  of  the  latter. 

Capillary  anastomosis  are  \  cr\  numerous  and  rich  and 
can  be  seen  in  any  portion  of  cardiac  musculature. 

Finally,  an  important  factor  in  anastomoses  and  one  u  Inch, 
as  will  be  seen  in  Chapter  VIII,  assumes,  particularly  in  the 
later  age  periods,  considerable  functional  significance,  is  that 
which  occurs  between  the  arteriae  telae  adiposae  cordis,  those 
\cssrls  which  lie  in  the  fatty  tissue  under  the  visceral  pericar- 
dium. The  author  has  traced  these  vessels  into  the  auricular  as 
well  as  ventricular  musculature  and  has  found  distinct  anasto- 
moses between  these-  and  branches  from  the  coronarj  arteries 
and  \ asa  \ asorum. 


Fig.   14  A. — An  enlargement  from  Fig.  i„ 


86 


Fig.   14. — Photograph    of   injected    and    cleared    specimen,    showing    the 
anastomoses  on  the  anterior  surface  of  the  heart. 


87 


THE  CORONARY  ARTERIES  89 

Lastly,  the  author  has  found  distinct  connections  between 
the  coronary  arteries  and  the  vessels  in  the  parietal  pericar- 
dium, so  that  this,  together  with  Langer's  observations  as  to 
the  existence  of  anastomoses  between  the  corollaries  and 
branches  of  the  bronchial  arteries,  arteriae  mammanae 
internae  and  those  of  the  diaphragm,  render  beyond  dispute 
the  fact  that  distinct  connections  exist  between  the  cardiac 
vasculature  and  that  of  the  adjacent  organs. 

If  one  now  turns  back  to  the  first  questions  with  which  the 
discussion  on  this  chapter  was  opened,  it  is  found  that  the 
following  statements  can  safely  be  made: 

(a)  Anastomoses  exist  between  the  right  and  left  coronary 
art (.-ries  both  in  their  capillary  as  well  as  precapillary 
distribution. 

(6)  Anastomoses  exist  between  the  branches  of  each 
coronary  artery. 

(c)  Anastomoses  exist  between  the  coronary  arteries  and 
vessels  from  the  adjacent  and  attached  organs. 

(d)  Anastomosis  in  the  heart  are  universal  and  abundant. 
The  question  which  now  arises  is  how  to  explain,  on  this 

basis,  the  formation  of  infarcts,  for  it  has  been  show  n  that  end- 
arteries,  in  the  anatomical  sense  of  Cohnheim,  do  not  exist  in 
the  heart. 

Pratt  has  formulated  a  definition  in  which  he  includes,  m 
the  category  of  junctional  end-arteries,  that  vascular  structure 
in  which  the  resistance  in  the  anastomotic  area  is  greater  than 
the  pressure  in  the  different  vessels.  To  a  certain  extent  only 
do  the  anastomoses  of  the  heart  fall  under  this  definition. 

It  has  been  stated  that  Ilirsch  found  in  his  experimental 
work  on  dogs,  and  this  has  been  confirmed  by  von  Recklinghausen 
and   Fujinami  as  true  for  the  human  heart,  that   in  normal 


9o  THE  BLOOD  SUPPLY  TO  THE  HEART 

hearts  the  infarcted  area  is  smaller  than  that  supplied  by  the 
obliterated  vessel.  When,  however,  the  pressure  in  the  blood  is 
lowered  or  perhaps  when  the  blood  is  rendered  poorer  in  its 
composition,  the  infarct  corresponds  completely  to  the  area 
supplied  by  the  vessel.  This  occurred  in  one  dog  upon  which 
Hirsch  experimented. 

Hirsch  concluded  from  these  experiments  that  infarcts 
can  occur  in  the  heart,  despite  the  anastomoses,  because  the 
heart  is  always  functioning.  He  believes  further,  that  the 
direction  and  extent  of  the  anastomoses,  the  structure  of  the 
vessels,  the  heart  strength  and  the  time  and  duration  ol  the 
obliteration  are  important  factors  in  this  connection. 

Amenomiya  concluded  from  his  study  of  infarcts  occurring 
in  papillary  muscles  that  for  an  infarct  to  occur  it  is  necessary 
to  have: 

(a)  Too  little  anastomoses. 

(6)  Closure  of  relatively  large  vessels. 

(c)   Rapid  blockage  of  the  vessel. 

It  is  generally  the  case  that  the  infarcted  area  is  situated 
on  the  inner  aspect  of  the  heart  (Smith,  Oppenheimer  and 
Rothschild),  but  it  is  occasionally  found  that  the  infarct  occurs 
in  the  outer  side  of  the  wall,  leaving  the  inner  surface  intact. 
This  variability  suggests  that  either  other  factors  besides  the 
anatomical  construction  can  dictate  the  occurrence  or  non- 
occurrence of  infarcts,  or  that  the  anatomical  structure  is 
fluid,  or  both. 

Spalteholz,  Galli  and  the  author  (Chapter  VII 1)  have  found 
cases  where  complete  and  almost  complete  obliteration  of  a 
coronary  artery   have  produced  no  lesion  in  the  myocardium. 

The  age  of  the  individual  is  of  prime  importance  in  this 
connection,  for  as  will  later  be  shown,  the  older  the  individual. 


THE  CORONARY  ARTERIES  91 

the  more  free  and  patent  are  the  anastomoses.  An  old  heart,  is 
therefore  much  more  prepared  to  receive  with  relatively  little 
or  no  damage,  the  brunt  of  a  sudden  obliteration  of  a  nutrient 
vessel. 

Moreover,  as  Herrick  has  stated,  a  gradual  obliteration 
of  a  vessel  allows  time  for  the  existing  anastomoses  to  widen 
and  compensations  to  take  place.  Here  the  arteriae  telae 
adiposae  are  of  considerable  importance,  more  especially 
in  the  heart  of  older  individuals. 

The  occurrence  of  an  infarct  on  the  outer  rather  than  on 
the  inner  aspect  of  the  heart,  as  in  a  case  shown  to  the  author 
by  Dr.  Rothschild,  was  undoubtedly  due  to  the  fact  that  here 
the  subendocardial  anastomoses  were  rich  enough  to  supply 
the  anemic  area. 

If  the  foregoing  facts,  therefore,  are  summed  up,  it  can 
be  concluded  that  in  the  ordinary  course  of  events  and  in  the 
average  young  adult's  heart,  the  intricate  systems  of  anas- 
tomoses are  all  in  active  function  and  are  not  prepared  to  act 
suddenly  as  entirely  adequate  compensatory  agents.  Never- 
theless, when  vascular  obliteration  takes  place,  a  certain 
amount  of  compensation  does  occur,  so  that  the  infarcted 
area  is  smaller  than  the  region  supplied  by  the  obliterated 
vessel,  the  remaining  portion  receiving  sufficient  nutrition 
from  the  anastomoses.  Moreover,  if  the  obliteration  is  gradual 
and  the  circulation  good,  sufficient  dilatation  of  the  anastomos- 
ing vessels  can  occur  to  preserve  considerable,  if  not  all,  ol 
the  musculature.  When  the  obliteration  occurs  in  a  relatively 
older  individual's  heart,  the  patent  and  free  anastomoses,  as 
well  as  the  well-developed  arteriae  telae  adiposae,  can  often 
amply  supply  the  affected  area  so  that  the  myocardium  can  be 
completely  spared. 


92  THE  BLOOD  SUPPLY  TO  THE  HEART 

Thus,  it  is  seen  that  in  the  determination  of  infarct  forma- 
tion, besides  the  factors  of  size  of  the  obliterated  vessel,  its 
location,  the  duration  and  rapidity  of  the  obliteration,  the 
condition  of  the  general  circulation  and  that  of  the  heart 
musculature,  another  very  important  one  must  be  added — 
namely,  the  age  of  the  individual. 


Chapter  VII 
The  Veins  of  the  Heart 

ON  account  of  their  rather  complicated  embryo- 
genetic  development,  the  veins  of  the  heart  are 
prone  to  considerable  variation. 
As  in  the  case  of  the  arteries,  a  description  will  here  be 
given  of  the  venous  structure  in  the  average  heart  (Fig.  15) 
and  this  w  ill  be  followed  by  a  short  discussion  on  the  variations. 
To  render  the  latter  somewhat  more  comprehensible,  a  brief 
description  of  the  embryogenesis  of  the  heart  veins  will 
precede  the  description  of  the  variations. 

The  veins  of  the  heart  can  be  divided  conveniently   into: 

(A)  Venae  magnae  cordis. 

(B)  Venae  parvae  cordis. 

(C)  Venae  minimae  Thebesii. 

A.  VENAE  MAGNAE  CORDIS 

The  term  Venae  magnae  cordis  has  been  chosen  as  a 
convenient  category  lor  the  largest  veins  ol  the  heart.  This 
must  not  be  confused  with  the  \  esse!  which  encircles  the  left 
auriculo\  (.'Utricular  furrow  to  empt\  into  the  sinus  coronarius 
and  which  is  called  by  some  vena  magna  cordis.  The  author 
feels  that  the  term  Vena  coronaria  sinistra  is  much  more 
suitable  for  the  latter,  and  one  less  open  to  contusion. 

Sinus  coronarius.  The  first  great  vein  which  is  to  be 
considered  is  the  Sinus  coronarius.  It  really  serves  largely 
as   a    collecting   receptacle   lor   blood    poured    into   it    from  the 

l>3 


THE  BLOOD  SUPPLY  TO  THE  HEART 

eins   of  the   heart,   and   which   it   in   turn 
-  T:its  to  the  right  auricle. 

There  has  been  considerable  dispute  as  to  whether  the 

...s  coTonarius  should  include  only  that  portion  of  the 

rly    which    is    covered    by    musculature     Reid, 

Marshall1  or  extend  beyond  this  to  limits  defined  by  various 

.  Cruveilhier).  As  Tandler  points 

sis     if  Marshall's  embryogenetic  classification, 

-       ~  >ry    boundaries    are   the  valvula  Thebesii 

".d  the  val  seuii  distally.   It  is  usually 

nded  in  its  entire  course  by  heart  musculature. 

ronarhis  thus  delimited  lies  in  the  po-" 
auriculoventricular  groove  and   extends,   usually  as  a  short 
•.    trunk    covered   with   transverse   musculature,    from   a 
nt  halfway  between  the  margo  obtusus  and  the  crux, 
si  1     the  left  of  the  crux. 
Vena  coronaria  cordis  sinistra.     Opening  directly  into  the 
nanus  through  the  valvula  vieusenii  and  continuous 
I     is  the  Vena  coronaria  cordis  sinistra.  This  is  a  large 
I    pers  from      -        gin  as  the  continuation  of  the 
aris  anterior  at  the  junction  of  the  auriculo- 
tricular  sulcus  _    .     _       as  it  rounds  the  margo 

"    •    -   in  the  furr        I  Dome  eventually  continuous  with 

the  sinus  coronarius. 

\  cna  mterventricularis  anterior.  This  vein  commences 
usually  at  the  lower  third  of  the  anterior  interventricular 
.1  wide  anastomosis  with  the  corresponding  posterior 
vein.  It  ascends  the  sulcus  in  company  with  the  ramus  de- 
scendens  anterior  of  the  left  coronary  artery  and,  at  the 
entricular  sulcus,  becomes  continuous  with  the 
vena  coronaria  cordis  sinistra. 


Fig.   15. — Roentgenogram  of  the  venous  distribution  in  the  average  heart. 


95 


THE  VEINS  OF  THE  HEART  97 

Vena  coronaria  dextra.  Another  constant  vein  which 
opens  into  the  sinus  coronarius,  is  the  Vena  coronaria  dextra. 
This  vein  is  rather  slender,  lies  in  the  auriculoventricular 
furrow  in  the  right  posterior  aspect  ol  the  heart  and  is  often 
the  direct  continuation  ol  the  vena  marginis  acuti. 

\  ena  marginis  acuti.  This  smaller  vein  commences  on 
the  lower  third  of  the  margo  acutus  as  a  distinct  anastomosis 
with  one  of  the  terminal  branches  of  the  \  ena  intcrventric- 
ularis  posterior.  It  rounds  the  junction  of  the  margo  acutus 
with  the  auriculoventricular  sulcus  to  become  the  vena  coro- 
naria dextra.  As  will  later  be  shown,  it  may  also  open  inde- 
pendently into  the  right  auricle. 

Vena  interventriculars  posterior.  This  [arge  and  tapering 
vein  commences  in  the  lower  third  ol  the  anterior  interven- 
tricular sulcus.  Anastomosing  at  its  origin  with  the  vena 
interventricularis  anterior,  and  receiving  anastomotic  twigs 
from  the  vena  marginis  acuti  and  venae  marginis  obtusi,  it 
rounds  the  apex  and  ascends  the  posterior  interventricular 
sulcus  to  empty  into  the  sinus  coronarius. 

Branches   \\  bicb  Enter  the   Venae  Magnae  Cordis 

Vena  obliqua  atrii  sinistri  (Marshalli).  Because  it  is  of 
considerable  embryogenetic  interest  and  marks  as  well  at  its 
entrance  the  beginning  ol  the  sinus  coronarius,  the  delicate 
auricular     vein     known     as    the     \  ena    obliqua     atrii    sinistri 

merits  Inst  description.  This  vein  commences  on  the  anterior 
Surface   ol    the    lelt    auricle   and,    proceeding    between    the  two 

left  pulmonarj  veins,  courses  diagonally  downward  and  toward 
the  right  ol  the  heart  to  empty  into  the  sinus  coronarius  about 
the  site  ol  the  \al\ula  \  icusenii. 

Venae  ventriculi  sinistri.     These  are  verj  large  veins  which, 


98  THE  BLOOD  SUPPLY  TO  THE  HEART 

on  the  left  side,  carry  blood  centripetally  from  a  point  two- 
thirds  down  the  margo  obtusus  as  the  center,  to  empty  into 
the  venous  ring  formed  by  the  linking  up  of  vena  coronaria 
cordis  sinistra,  vena  interventricularis  anterior  and  vena 
interventricularis    posterior. 

According  to  their  situation  they  are  called  Venae  ven- 
triculi  sinistri  posteriores,  marginales  or  anteriores. 

Venae  ventriculi  dextri.  On  the  right  side,  the  venous 
chain  is  not  so  large  and  consists  of  the  linking  up  of  vena 
marginis  acuti,  vena  coronaria  dextra  and  vena  interventric- 
ularis posterior. 

Into  this  ring  there  course  centripetally  and  empty,  veins 
which  are  not  so  large  as  those  found  on  the  left  side.  These 
are  known  on  the  posterior  surface  of  the  right  ventricle  as 
Venae  ventriculi  dextri  posteriores.  Here  they  usually  pursue 
a  remarkably  even  horizontal  course,  parallel  one  to  the  other. 

Finally,  in  the  interventricular  septum  there  are  found 
numerous,  large  and  richly  interanastomosing  veins  which 
empty  into  the  anterior  and  posterior  venae  interventriculares. 

The  topmost  of  these  empties  into  the  vena  interventri- 
cularis posterior.  It  accompanies  the  ramus  septi  fibrosi  through 
the  bundle  and  shows  a  wide  anastomosis  with  a  more  delicate 
vessel  which  empties  into  the  vena  interventricularis  anterior. 

There  remains  the  description  of  the  veins  draining  the 
anterior  surface  of  the  right  ventricle.  This  is  accomplished 
by  two  systems:  (i)  venae  ventriculi  dextri  anteriores; 
(2)  venae  parvae  cordis. 

The  Venae  ventriculi  dextri  anteriores  are  transverse  richly 
anastomosing  veins  which  empty  into  the  vena  marginis 
and  vena  interventricularis  anterior. 


THE  VEINS  OF  THE  HEART  99 

B.    VENAE    PARVAE    CORDIS 

It  will  be  seen  that  the  auriculoventricular  sulcus  is  sur- 
rounded by  veins  in  its  whole  circumference  with  the  exception 
of  that  part  which  lies  between  the  margo  acutus  and  anterior 
interventricular  sulcus. 

It  is  over  this  portion  of  the  sulcus  that  the  second  group 
of  veins,  draining  the  anterior  surface  of  the  right  ventricle, 
cross  to  empty  directly  into  the  right  auricle. 

These  consist  of  three  or  four  relatively  small  veins  which 
run  parallel  to  one  another  and  show  wide  anastomoses  in 
their  ventricular  aspect. 

Two  other  venae  parvae  cordis  deserve  some  special  men- 
tion. One,  which  empties  into  the  right  auricle  between  the 
root  of  the  pulmonary  artery  and  the  appendage,  corre- 
sponds to  the  constant  arterial  arch  already  described  at 
the  junction  of  the  conus  with  the  pulmonary  artery  (Cru- 
veilhier)  and  anastomoses  with  a  corresponding  vessel  which 
empties  into  the  right  auricle  alter  draining  blood  from  the 
roots  of  the  aorta  and  pulmonary  artery  and  adjacent  portion 
of  the  right  auricle  ( Zuckerkandl). 

For  the  rest,  a  number  of  small  auricular  veins  which 
empty  for  the  most  part  into  the  vena  coronaria  sinistra  and 
which  show  some  correspondence  with  the  auricular  arteries, 
constitute  the  remaining  venae  parvae  cordis. 

Of  the  veins  thus  far  described,  the  main  trunks  usually 
accompany  branches  of  the  coronary  arteries  and,  in  these 
eases,  occupy  a  position  beside  them  or  lying  upon  them. 
The  smaller  ramifications  may  lie  subjacent  to  the  arteries. 
The  deeper  divisions  of  the  veins  differ  from  the  arteries  in  that 
they  do  not  form  so  regular  a  series  of  dichotomous  branching 


ioo  THE  BLOOD  SUPPLY  TO  THE  HEART 

but  course  to  the  surface  as  somewhat  tortuous,  delicate, 
interlinking  channels  which  join  up  at  the  surface  and  abruptly 
empty  into  the  larger  superficial  trunks  of  the  second  and  third 
order.  At  the  apex,  there  is  often  seen  a  well-formed  medusa- 
head  whorl  of  delicate  veins  which  empty  into  the  terminal 
branches  of  the  venae  interventricularis  anterior  and  posterior. 
At  the  root  of  the  aorta  and  in  the  subpcricardial  fat,  a  well 
formed  structure  of  venae  telae  adiposae  can  also  be  formed. 

C.    VENAE    MINIMAE   THEBESI  I 

It  has  been  seen  that  with  the  exception  of  the  vena 
obliquaatrii  sinistri  and  the  vein  described  by  Zuckerkandl,  there 
are  practically  no  veins  of  larger,  caliber  draining  the  auricles. 
This  lack  is  largely  made  up  for  by  the  existence  of  tiny  venous 
channels  known  as  Venae  Thebesii  according  to  their  discoverer 
Thebesius,  who  described  them  independently  and  unaware 
of  the  fact  that  Vieussens  had  already  made  known  their 
presence. 

Their  existence  has  been  open  to  much  discussion,  having 
been  confirmed  by  Winslow,  Verheyen,  Lancisius,  Bochdalek, 
Henle,  Hyrtl  and  others,  and  denied  by  Senac,  Zinn,  Haller, 
Cruveilhier,  Theile  and  Luschka. 

Bochdalek,  moreover,  proved  their  existence  in  both 
auricles  and  this  was  later  confirmed  by  Langer.  Those  who 
denied  the  existence  of  these  tiny  channels  as  carriers  of 
venous  blood,  held  them  to  be  blind  diverticulae.  Haller 
claimed  that  their  function  as  veins  meant  admixture  of 
venous  blood  with  the  arterial  on  the  left  side,  which  seemed 
improbable  on  physiological  grounds. 

The  openings  of  these  channels,  known  as  Foramina 
Thel>esn  are,   however,   very   easily  seen,   particularly   in   the 


THE  VEINS  OF  THE  HEART  101 

auricles.  That  they  communicate  with  the  general  venous 
system  can  readily  be  proved  by  injections.  These  experiments 
have  been  successfully  carried  out  by  Thcbcsius,  Langer,  and 
the  author.  Recently,  the  existence  of  venae  Thebesii  in  the 
ventricles  has  been  proved  in  a  similar  manner.  This,  however, 
has  been  denied  by  Nussbaum. 

These  vessels  can  be  divided  into  two  types:  (a)  With  \er\ 
small  openings,  1-2  mm.  in  width,  which  drain  the  capillaries 
in  the  auricles;  (/>)  with  larger  openings,  in  which  several  sec- 
ondary openings  can  be  seen,  and  which  link  up  with  large 
venous  channels  m  the  musculature  and  on  the  surface  ol  the 
heart. 

The  venae  minimae  Thebesii  are  very  numerous  in  the 
right  auricles,  being  seen  in  greatest  numbers  in  the  interauric- 
ular  septum,  especially  in  the  region  of  the  hmbus  Vieussenii 
and  valvula  Thebesii.  In  the  left  auricle  they  are  not  so  numer- 
ous, but  generally  larger.  Thus,  Langer  has  shown  that,  on 
the  interauricular  septum  adjacent  to  the  aortic  valves,  cer- 
tain larger  venous  openings  can  be  found  which  dram  as  well 
in   part   the  superior  portion  of  the  interventricular  septum. 

It  is  possible  that  into  the  category  of  veins  fall  also 
the  long  grooves  described  by  Lannelongue.  II  one  ol  these  is 
injected,  the  injection  mass  is  forced  out  of  the  adjoining 
groove.  Tandler  does  not  feel  that  he  can  confirm  with  cer- 
tainty Lannelongue' s  statement  that  these  grooves  drain  small 

\  enous  channels. 

In    the   ventricles,    foramina    rhebesii    are  most   frequent 

at  the  liases  ol  the  papillarx  muscles,  the  region  of  the  (.'onus 
on  the  right  side,  and,  according  to  Langer,  the  apical  mus- 
culature. 1  hex  do  not  hert-  communicate  directlj  with  the 
larger   veins  except    possibly   through   capillary   anastomoses. 


io2  THE  BLOOD  SUPPLY  TO  THE  HEART 

and  appear  to  be  concerned  more  with  draining  the  subendo- 
cardial spaces  and  the  immediately  adjacent  musculature. 

VARIATIONS    IN    THE    VEINS    OF    THE    HEART 

As  has  already  been  stated,  the  venous  structure  of  the 
heart  is  very  liable  to  variations.  Some  of  the  more  outstand- 
ing and  interesting  variations  can  easily  be  explained  on 
an  embryological  basis. 

Very  early  in  embryonic  life,  the  anterior  and  posterior 
cardinal  veins  link  up  to  form  the  ductus  Cuvieri,  and  these 
in  turn  open  separately  into  the  heart.  Normally,  only  the 
right  opening  persists  and  this  is  made  possible  by  the  develop- 
ment of  a  great  anastomosis  between  the  anterior  cardinal 
veins,  which  enables  the  left  vein  to  conduct  all  its  blood  into 
the  right  auricle.  The  lower  portion  of  the  right  anterior 
cardinal  vein  and  the  right  ductus  Cuvieri  become  the  vena 
cava  superior  of  the  right  side.  The  corresponding  structure 
on  the  left  side,  as  has  been  shown  by  Marshall,  regresses  so 
that  only  vestiges  remain  of  the  greater  part  of  the  left  superior 
vena  cava — namely,  the  vena  obliqua  atrii  sinistri  and  the  plica 
venae  cavae;  only  the  proximal  portion  of  the  left  ductus 
Cuvieri  is  preserved  as  the  sinus  coronarius. 

When  the  opening  of  the  coronary  sinus  into  the  right 
auricle  is  obliterated,  blood  is  carried  through  a  persistent 
left  superior  vena  cava  into  the  vena  innominata.  This  oblitera- 
tion, as  Siding  has  shown,  must  occur  necessarily  in  the  second 
month  of  embryonic  life  and  at  a  time  after  the  formation  of 
the  vena  innominata. 

Tandler  cites  2  cases,  that  of  Le  Cat  (1738)  and  that 
of  A.  Siding  (1896),  where  this  condition  occurred.  Here  the 
sinus  coronarius  commences  as  a  trunk  which  runs  obliquely 


THE  VEINS  OF  THE  HEART  103 

over  the  posterior  wall  of  the  left  auricle  in  front  of  the  left 
pulmonary  veins,  through  the  Iigamentum  venae  cavae  to 
reach  and  empty  into  the  vena  innominata.  The  opening  of  the 
sinus  coronarius  into  the  right  auricle  is  obliterated.  Extending 
out  from  the  right  auricles,  through  an  opening  flanked  by  a 
low  valvula  Thebesii,  is  a  blind  sac  about  10  mm.  in  length 
and  representing  the  proximal  portion  of  the  sinus  coronarius. 
The  patent  portion  of  the  sinus  coronarius,  which  continues 
up  towards  the  pulmonary  veins,  receives  the  entrance  of  the 
vena  coronaria  sinistra  and  the  vena  interventricularis  poste- 
rior through  openings  guarded  by  valves. 

The  above  described  condition  is  infrequent  but  deserves 
special  mention  on  account  of  its  interesting  genesis. 

A  frequent  variation  and,  according  to  Piquand  who  found 
it  in  20  per  cent  of  the  cases,  representing  the  primitive 
form,  is  the  entrance  of  both  vena  coronaria  sinistra  and 
vena  interventricularis  posterior  by  a  common  short  channel, 
the  truncus  communis. 

In  a  number  of  hearts,  the  vena  marginis  acuti  empties 
independently  into  the  right  auricle  and  is  then  called  the 
Vena  Galeni. 

The  vena  coronaria  dextra  frequently  varies  in  its  site  in  the 
auriculoventricular  groove,  being  often  found  lying  above 
this  in  the  auricular  musculature. 

Not  infrequently  a  stout  vena  marginis  obtusi  ascends  the 
surface  of  the  ventricle  and,  curving  parallel  with  the  vena 
coronaria  sinistra,  opens  independently  into  the  sinus 
coronarius. 

The  venae  minimae  Thebesii  are  liable  to  much  variation 
in  their  size,  form  and  situation. 

So  far  as  structure  is  concerned,  it  has  already  been  stated 


io4  THE  BLOOD  SUPPLY  TO  THE  HEART 

that  the  sinus  coronarius  is  usually  surrounded  by  transverse 
muscular  fibers  from  its  origin  to  its  conclusion  at  the  valvula 
Vieussenii.  The  musculature  may  fall  short  of  the  valves  but 
never,  according  to  Tandler,  passes  beyond  them. 


Chapter  VIII 

Age  Period  Changes  in  the  Blood  Supply  to  the  Heart  \\i> 
their  Pathogenetic  Relations 

IN  introducing  the  discussion  on  the  age  period  changes 
which  the  blood  supply  to  the  heart  undergoes,  it  may  be 
permissible  to  quote,  slightly  modified,  from  the  author's 
article  on  the  postnatal  evolution  ol  the  spleen,  in  order  to 
make  clear  the  general  importance  ol  the  subject: 

Various  integral  parts  of  the  human  organism  die  long  before  the  whole 
organism  is  born.  Birth  and  growth  of  new  tissues  continue  long  alter  the 
whole  organism  is  bom.  Life,  in  fact,  consists  of  the  simultaneous  breaking 
down  and  building  up  ol  protoplasm,  cells,  tissues  and  organs. 

I  mbryonic  development  presents  some  of  these  phenomena  in  striking, 
almost  dramatic,  form.  Moreover,  it  appears  that  these  processes  display, 
at  least  m  some  instances,  a  coordinated  relationship. 

Oertel  was  the  first  to  show  that  tin-  development  and  growth  ol  the 
sex  gland  in  the  embryo  is  definitelj  correlated  with  the  degeneration  ol 
the  mesonephros,  and  thus  gave  an  actual  anatomic  foundation  to  the 
idea  that  the  relationship  of  cells,  tissues  and  organs  is  by  no  means  always 
altruistic,  but,  as  held  many  years  ago  l>\  Boll,  Roux,  Hansemann  and 
Others,  often  antagonistic. 

Life  and  evolution  ol  the  individual,  like  hie  and  evolution  ol  an\ 
community,  depend  not  only  upon  hoi  pi  n  I  but  also  upon  opposing  forces, 
rhese  phenomena  ol  embryonic  life  possess  an  additional  interest  to  the 
pathologist  because  almost  all  pathological  processes,  degenerations, 
inflammations  and  even  tumor  growth,  are.  as  Minol  pointed  out  years 
ago,  in  principle  and  prototype  to  be  found  in  the  normal  embryo. 

In  postnatal  hie,  the  appreciation  of  the  unstable  and 
constant  l\  changing  character  of  cells,  tissues  and  organs  has 
in  recent  years  been  somewhat  more  lulb  recorded  especially 
since  their  pathogenetic     importance  has  become  clear.  Thus, 


106  THE  BLOOD  SUPPLY  TO  THE  HEART 

since  Reid's  observations  on  the  measurements  of  the  heart 
and  tables  on  the  weight  of  the  most  important  organs  of  the 
body  at  the  different  age  periods  appeared  in  1843,  several 
other  important  contributions  on  different  organs  have  helped 
to  show  that  these  changes  represent  a  general  principle  of  life. 

In  1883  Miiller  presented  his  observations  on  the  weights 
and  measurements  on  the  heart  and  its  structures,  and  though 
he  did  not  particularly  stress  the  age  period  idea,  his  carefully 
compiled  statistics  based  on  a  very  large  number  of  hearts 
furnish,  as  will  be  shown  later  in  the  discussion,  a  great  number 
of  very  interesting  points. 

It  may  be  well,  however,  to  outline  here,  first,  the  present 
knowledge  regarding  postnatal  development  in  other  organs 
of  the  body,  thus  showing  the  significance  of  age  period  changes 
and  of  the  fluid  state  of  tissue. 

In  1904,  Reitmann  pointed  out  that  the  normal  pancreas  is, 
from  infancy  to  old  age,  a  very  unstable  organ.  Degeneration, 
atrophy,  cell  loss  and  acinar  collapse  are,  to  a  certain  extent, 
normal  performances,  being  almost  simultaneously  com- 
pensated for  by  formation  of  new  cells,  new  acini  and,  in  the 
growing,  youthful  pancreas,  even  by  the  formation  of  new 
lobules. 

Coplin  found  equally  great  instability  in  the  thymus, 
Theilhaber  in  the  endometrium,  and  Milne  in  the  ductless 
glands,  chiefly  the  thyroid  and  suprarenal  gland. 

In  1909,  Herxheimer  called  attention  to  the  frequent 
occurrence  of  hyaline  glomeruli  in  the  kidneys  of  infants  and 
young  children.  These,  Oertel  regards  as  remnants  of  reduced 
and  regressing  renal  substance  similar  to  those  found  in  other- 
wise healthy  adult  kidneys  without  arterial  disease. 

Oertel,  and  Oertel  and  Anderson,  have  more  recently  been 


AGE  PERIOD  CHANGES  IN  THE  BLOOD  SUPPLY    107 

able  to  corroborate  and  to  extend  Reitmann's  observations  on 
the  pancreas  and  to  show  further  that  certain  localized  re- 
stricted abnormalities  or  faulty  reconstructions  may  even  nor- 
mally be  found,  making  it  at  times  difficult  to  define  on  which 
side  of  the  borderline  between  physiologieal  and  pathological 
they  may  be  classified.  Thus  also  the  condition  which  Oertel 
has  called  "Essential  Atrophy  of  the  Pancreas"  appears,  as  he 
states,  to  represent  a  pathological  exaggeration  of,  and  loss  of 
balance  in,  normal,  physiological  processes  of  regression  and 
progression  which  are  constantly  going  on   in  the  pancreas. 

In  his  studies  on  degeneration,  senescence  and  new  growth, 
Oertel  has  further  drawn  attention  to  the  close  interrelation 
between  these  normally  occurring  processes  and  distinct 
pathological  conditions.  Somewhat  similar  observations  have 
been  made  by  Rene  Sand  in  a  study  of  pathological  senescence. 

In  i()K),  the  author  was  able  to  add  the  spleen  to  the 
already  growing  list  of  organs  showing  a  distinct  cycle  of 
progressive  and  retrogressive  processes  during  the  age  periods, 
and  pointed  out  that  age  has  a  most  important  bearing  both  as 
regards  the  anatomical  structure  of  the  spleen  in  health,  as 
well  as  to  the  reaction  which  it  presents  in  disease. 

In  U)2o,  Waugh  came  to  similar  conclusions  on  the  bone- 
marrow  and  this  was  soon  followed  by  Weed,  whose  studies 
convinced  him  that  very  definite  qualitative  structural  modi- 
fications occur  in  the  pia  arachnoid  in  advanced  age  periods, 
notably  in  the  appearance  of  newly  formed  endothelial  cell 
clusters,  etc. 

Finally  in  1921  Oertel  summed  up  the  existing  tacts  on 
postnatal  evolutions  and  pathological  organ  reconstruction 
in  its  relation  to  function  and  disease  and  came  to  the  following 
conclusions: 


io8  THE  BLOOD  SUPPLY  TO  THE  HEART 

(i)  Organs  which  normally  exhibit  a  developmental  cycle  of  changes 
in  cell  elements  and  tissue  organization,  undergo  corresponding  functional 
modifications.  Pathological,  anatomical  and  functional  changes  must, 
therefore,  be  interpreted  in  conformity  and  comparison  with  an  age 
period. 

(2)  Disposition  to  disease  is  influenced  by  structural  alterations  in 
tissue  soil  in  the  various  age  periods,  especially  in  affording  or  not  affording 
anchoring  ground  for  bacteria.  Moreover,  it  is  likely  that  the  fluid  con- 
dition of  organs  influences  the  disposition  to  infections  during  waves  of 
regression  and  progression  as  we  already  know  it  in  unbalanced,  juvenile 
and  growing  tissues. 

(3)  Anatomical  and  functional  expressions  of  a  disease  vary  in  one 
and  the  same  organ  according  to  its  construction  and  composition  during 
an  age  period,  and  it  would  seem  that  these  factors  also  exert  an  influence 
on  variations  in  disposition  and  immunity.  (The  author  has  shown  this 
to  be  true  in  endocarditis,  and  Lexer  in  osteomyelitis.) 

(4)  Diseases  may  arise  from  the  fluid  and  changing  state  and  age 
progress  of  organs  by  loss  of  balance  in  physiological  regression  and 
progression. 

(5)  Depending  upon  the  pathological  predominance  of  one  or  the 
other  group  of  changes,  essential  atrophies,  hypertrophies,  degenerations 
and  progressive,  destructive  cell  proliferation,  all  of  which  are  normal 
developmental  processes,  may  be  duplicated  and  exaggerated  in  post- 
natal existence. 

Thus,  Oertel  has  elevated  the  importance  of  postnatal  age 
period  changes  to  a  general  biological  principle  upon  which 
depends  the  evolution  of  the  individual  from  birth  to  senility 
and  the  development  of  disease. 

One  is  now  in  a  better  position  to  appreciate  similar 
changes  in  the  heart,  for  the  vascular  architecture  of  the  heart 
shows  strikingly  the  remarkable  effect  of  age  periods  in  pro- 
ducing a  cycle  of  events  which  register  unmistakably  their 
effects  on  (unction,  both  physiologically  and  pathologically. 
Moreover,  these  changes  occur  not  only  in  the  absolute  sense, 
but  also,  as  will  be  seen,  in  the  relative  constitution  and 
construction  of  both  sides  of  the  heart. 


AGE  PERIOD  CHANGES  IN  THE  BLOOD  SUPPLY    109 

Bizot  has  shown  long  ago  that  in  the  embryo  both  ventri- 
cles arc  about  the  sanu-  thickness;  at  birth  tin-  left  is  slightly 

thicker,  and,  after  this,  outstrips  the  right  in  growth  so  that  it 
gradual!}    becomes  relatively    more  and   more  preponderant. 


15i        2-°       3s-0        4T-*       J-        6T-=       7^      6-       9- 

B1RTH    DECADE  DBCADE  DECADE  DECADE  DECADE  DECADE  DECADE  DECADE  DECADE 


70pM 
00  •• 

m  ■• 

40  •■ 

50  •• 

20  ■• 

10  - 

0  » 

Fig.  16. — Graph  showing  the  increase  "I  subpericardial  fatty  tissue  as  age 
,i<!\  ances. 


The  development  oi  fat  under  the  pericardium  he  lound  to 
begin  always  at  the  base  ot  the  heart  and  to  follow  the  right 
coronary  artery  to  the  apex,  later  the  hit  coronary;  Imalb  the 
rest  of  the  organs  become  the  seat  of  fat  deposit.  The  amount 
ol  subcutaneous  fa1  bears  no  relation  to  the  amount  ol  sub- 
pericardia]  fat. 

Valentin,    Engel    and    Beneke    studied    the    relationship 
between  the  right  and  lelt  ventricles.  Judging  l>\  then  figures 


THE  BLOOD  SUPPLY  TO  THE  HEART 


there  is  an  undoubted  relatively  greater  increase  on  the  left 
side,  which  reverses  in  the  later  decades  of  life. 

Miiller  ( 1 877-1881)  made  a  study  of  1,481  hearts.  From 
observations  on  their  gross  weight  he  concluded  that  the 
turning  point  in  growth  of  the  heart  is  in  the  seventh  decade  in 
men  and  the  eighth  decade  in  women. 

Though  he  held  that  there  is  a  relative  proportion  between 
the  amount  of  subpericardial  and  subcutaneous  fat,  his  figures 
show  a  distinct  and  gradual  increase  in  the  former  from  birth  to 
death.  Figure  16  shows  this  process  graphically  in  a  chart  which 
the  author  has  plotted  out  from  Midler's  statistics. 

A  study  of  his  figures  on  the  comparison  of  the  weight  of 
the  right  and  left  auricle,  in  regard  to  age  periods,  shows  that, 
on  the  whole,  there  is  very  little  difference  between  the  two. 

His  figures  expressed  in  units  of  proportion  (Table  VIII)  are 
as  follows: 

TABLE  VIII 


Male 


Female 


Age 


Embryos 

1  Month 

2-12  Months. 
2- 1 5  Years . . . 
16-20  Years. . 
21-80  Years. . 


Right 
auricle 


i-7 
1.6 

1-7 

1-7 


Left 

auricle 


>  5 
i-5 

1.7 
1.6 
1.6 

1.7 


Right 
auricle 


Left 

auricle 


[.4 
■4 
.6 
•7 
6 
■  7 


From  these  he  draws  the  following  conclusions: 

(a)  The  division  of  the  auricular  musculature  of  both  auricles  is  different 
before  and  after  birth.  During  the  whole  embryonic  life,  the  muscle  mass 
preponderates  in  the  right  auricle.  During  the  first  month  after  birth,  the 
right  auricle  loses  in  weight.  At  the  beginning  of  the  second  month,  both  are 
similar  in  weight.  This  equality  more  or  less  persists  during  the  first  year. 

(b)  From  the  second  year  of  life  until  the  period  of  maturation  of  sex, 
the  left  auricle  preponderates,  after  which  the  right  again  preponderates. 


AGE  PERIOD  CHANGES  IN  THE  BLOOD  SUPPLY    1 1 1 


Much  more  interesting  and  important  in 
are  his  figures  comparing  the  mass  of  the  right 
cles  according  to  age  periods  (Table  IX). 

TABLE  IX 


this   connection 
and  left  ventri- 


Male 

Female 

Age 

No.  1 
of        R. 
cases  | 

-  :.. 

No. 

of    |    R. 
cases  1 

L. 

R. 

L. 

Embryos  i    500  gms. 

10     0  42 

0  $6|o  845 

6     0.37 

0   39 

0  -31 

50 1    1 000  gms 

9  I   ii3 

I.  I7I0.769 

7  |  1.29 

1 .  40 

0  -10 

1 001-1500  gms 

4    \   2    3^ 

2.04  0   S42 

10  1  2.45 

2.  28 

0.811 

1  501    2"00  gms 

11        341 

3.06  0  864 

ii      3 . 06 

2.59 

0.902 

2001-2,00  gms. 

6     4  31 

4.04I0.85 

6     398 

4.i8|o  786 

2501    5000  miis 

6     6  02 

4.84  0  925 

-      5  46 

4  020.849 

over  3000  gms 

15     7. 72 

5  44  1    007 

7  |   "    14 

4  69  1  065 

1  week  post-natal 

16  |  4.85 

4  4,-0  839 

17  |   3-82 

3.47I0.827 

2  weeks 

13  I  4-H 

4.79I0.698 

15   |  4.  10 

4    53  0  -33 

10  |  4. 10 

4.93I0.680 

5      4.04    5.040.678 

5      4   1  ' 

5  83  0  635 

10      3  44    4. -10. 638 

14      5  09 

4   54I0.594 

14       3  43    5.42I0.571 

3  months 

14       3  "4 

6.44I0.561 

16  |  3.88    6.  J.1I0.  «A« 

-    ill    0    ,22 

24     4  68 

-  000   ,-32 

20      4    33 

-    12  months 

34       5   "2 

10  68  0  502       31      5.  —  10  43:0.515 

1-      0  00 

14. no. 561       24      -.8213.520.525 

13     in  dj 

23  — 0  469       10      9  04  18  200.4-3 

17  |n.07 

22.23  0  4"3        ■"    11   "i-i   94  0.499 

16    1-  68 

33. 080.48-!     21     14.3121.020  _l-i 

0  _i.fi- 

8    24.20 

44  .  4o|o.  50o||        Q    20.1040.90 

23    46.00 

-0000.542        13    39.10-3.800.508 

1 1    30  \ears 

69    ;  i   u 

1    QO.50lo.5iol       46     1-.  Qol-2.  Qolo.  .ton 

67    -;o  8< 

88. 9o|o. 529H     5-    3-  -008.90 

I    82    5  1  -< 

04   (jo  0    500        '»j     45.20-5    200    552 

*4    S4  ')' 

101    6o|o    ,-oS        58    43    3"  "3   "oo    52(j 

6i  70  3  ears 

87    S5   n 

103   70  0    i  10        S3     4(1  doNi    20  0    545 

62    52  4c 

94.40  0  526       6i     43  90  82.  -0  0  yi  5 

Si    1/0  \  (Mis 

11    41.2c 

97  20I0.442II      12     jo   iolfifi   100    t88 

ii2  THE  BLOOD  SUPPLY  TO  THE  HEART 

Represented  in  chart  form,  the  gradual  and  consistent, 
increasing,  postnatal  preponderance  of  the  left  over  the  right 
ventricle  as  age  advances,  is  strikingly  seen  (Fig.  17). 


3IRTH 

DECADE  DECADE  DECADE  DECADE  DECADE  DECADE  DECADE  DECADE  DECADE 

OOffe 
90  •■ 

-—     1 

80  •• 

70-  •■ 

60  » 

50  " 

40  •• 

^ 

50  •• 

20  " 

10  •■ 

0    • 

LEFT  VENTRICLE 


Kim  VENTRICLE 


Fig.  17.— Graph  showing  the  absolute  increasing  weight  of  the  right  and 
left  ventricles  as  age  advances,  and  also  the  relative  increasing  pre- 
ponderance of  left  over  right  side. 

Councilman  has  recently  come  to  the  conclusion  that  heart 
hypertrophy  is  very  frequent  in  old  people  and  regards  it  as 
pathological. 

Lewis  has  been  able  to  confirm  Einthoven's  observations 
that  before  birth  and  for  several  months  after,  the  heart  shows 
electrocardiographically    a    right-sided    preponderance   which 


AGE  PERIOD  CHANGES  IN  THE  BLOOD  SUPPLY    113 

soon,  however,  becomes  equal  and  from  then  on  becomes  pre- 
ponderant in  the  left.  Unfortunately,  accurate  comparative 
age  period  observations  on  this  point  arc  wanting  for  the  post- 
natal development  of  the  heart,  but  Lewis  and  others  have 
observed  electrocardiographic  curves  in  adults  which  speak 
for  left-sided  hypertrophy  in  apparently  normal  cases.  In  old 
individuals,  relative  preponderance  of  the  left  ventricle  is  a 
common  observation. 

In  consideration  of  all  the  foregoing  facts,  it  is  not  sur- 
prising that  the  cardiac  circulatory  architecture  shows  a 
corresponding  series  of  changes  which,  in  their  qualitative  and 
quantitative  nature,  are  of  prime  physiological  and  pathologi- 
cal importance. 

If  one  examines  Figure  18,  which  represents  a  roentgeno- 
gram of  the  circulation  in  an  a\  erage  heart  at  birth,  it  isscen  that 
both  sides  of  the  heart  are  equally  divided  and  supplied  with 
blood,  so  that,  were  it  not  lor  the  characteristic  ramus  cir- 
cumflexus  dexter,  one  would  be  at  a  loss  to  discern  the  [eft 
from  the  right  side.  Examined  stereoscopically,  this  heart 
lails  to  show  macroscopic  septal  anastomoses.  I  he  branches 
show  a  uniformity  oi  lumen,  and  are,  with  the  exception  ol 
their  extremities,  on  the  whole  without  tortuosity. 

Figure  10  is  a  photograph  of  injected  and  cleared  specimens 
of  hearts  at  birth.  It  will  be  seen  that  at  this  period  of  life  no 
arteriae  telae  adiposae  arc  visible  in  the  subpericardial  hit,  so 
that  the  aunculovcnt ricular  sulci  carry  no  fat-vessels,  nor  do 
these  accompany  the  mam  coronarj  branches. 

Figure  20  represents  an  average  heart  of  the  Inst  decade. 
In  this  roentgenogram  the  main  branches  pursue  a  straight  and 
1  \  en  course.  There  is  a  beginning  clearing  of  the  right  side.  Septal 
anastomoses  cannot  yet  be  made  out.  This  heart  did  not  show, 


ii4  THE  BLOOD  SUPPLY  TO  THE  HEART 

upon  examination  of  the  cleared  specimen,  any  arteriae 
telae  adiposae. 

In  the  second  decade  (Fig.  21),  the  distribution  of  blood  is 
beginning  to  be  a  little  more  marked  on  the  left  side.  The 
vessels  have  hardly  commenced  to  show  their  tortuosity.  The 
stereoscope,  however,  already  reveals  very  delicate  septal 
anastomoses.  At  the  furrows,  the  cleared  specimen  shows  a  few 
stray  fat-vessels,  best  seen  as  rami  telae  adiposae  parallel  to 
the  main  branches. 

The  third  decade  of  life  (Fig.  22)  shows  a  definite,  though 
not  yet  marked,  left-sided  vascular  preponderance.  Septal 
anastomoses  are  now  much  more  clearly  made  out.  The  tor- 
tuosity of  the  vessels  is  quite  discernible  and,  in  the  cleared 
specimen,  rami  telae  adiposae  are  well  seen. 

The  fourth  decade  of  life  presents  these  changes  in  definite 
progress  (Fig.  23).  The  septal  anastomoses  are  quite  clearly 
developed.  The  left  side  of  the  heart  is  definitely  in  the  ascend- 
ant. Tortuosity  of  vessels  is  clearly  seen  and  becoming  marked. 

Figure  24  is  a  photograph  of  an  average  injected  and 
cleared  heart  from  this  decade.  It  shows  the  already  well- 
developed  fat-vascular  system.  It  will  be  seen  that  the  anterior 
surface  of  the  heart  displays  in  the  auriculoventricular  groove 
a  striking  network  of  delicate  arteriae  telae  adiposae.  At  the 
edges  of  the  heart  these  are  seen  projecting  from  the  surface 
into  the  subpericardial  fat.  The  parallel  fat-vessels  can  quite 
easily  be  made  out  as  they  accompany  the  main  branches, 
particularly  the  ramus  descendens  anterior. 

Figure  25  shows  the  posterior  surface  oi  the  same  heart. 
Here,  there  is  displayed  even  better,  the  well-developed  net- 
work of  arteriae  telae  adiposae.  It  fills  the  whole  auriculo- 
ventricular groove  and  appears  as  a  greyish  maze  of  vascular 


Fie.   18. — Roentgenogram  oi'tlie  blood  supply  in  the  average  heart  at  birth. 


Fig.   19.  -Photograph  of  injected  and  cleared  specimen,  showing  the  super- 
ficial distribution  of  the  coronary  arteries  at  birth. 


1 '5 


I 


V 


I  [G    20. — Roentiii  1 ram  "I  the  blood  supply  in  the  average  heart  ol  the 

first  decade. 


117 


Fig.  21. — -Roentgenogram  of  the  blood  supply  in  the  average  heart  of  the 
second  decade. 


119 


Fig.  22.     Roentgenogram  of  the  blood  supply  in  the  average  heart  ol  the 
third  decade. 


r~*t 


*? 


Vi 


Fig.  23.  —  Roentgenogram  of  the  blood  supply  in  the  average  heart  ol  the 
fourth  decade. 


'23 


Fig.  24. — Photograph  of  t he  anterior  surface  of  an  injected  and  cleared 
heart  of  the  fourth  decade,  showing  the  distribution  of  the  arteriae 
telae  adiposae. 


Fig.  2j. — Photograph  of  the  posterior  surface  of  the  same  heart  as  in  Fig 
24,  showing  tlu-  distribution  of  the  arteriae  telae  adiposae. 


V 


*r    j 


Fig.  26.     Roentgenogram  ol  the  blood  supply  in  the  average  heart  oi  the 
fifth  decade. 


129 


Fi ::.  2-.— Roentgenogram  of  the  blood  supply  in  the  average  heart  of  the 
sixth  decade. 


vi^ 


Fig.  28.     Roentgenogram  of  the  blood  supply  in  the  average  heart  "I  the 
>r\  enth  decade. 


'33 


9 


Fig.  K). — Roentgenogram  of  the  blood  supply  in  the  average  heart  of  the 
eighth  decade. 


'3. 


AGE  PERIOD  CHANGES  IN  THE  BLOOD  SUPPLY    137 

channels.  Here  too,  the  accompanying  fat-vessels  are  clearly 
seen. 

In  the  fifth  decade  (Fig.  26)  the  preponderance  oi  left 
side  o\  er  right  is  striking,  as  is  also  the  tortuosity  of  the  vessels. 
At  this  period  of  life  the  main  branches  are  occasionally  seen 
fas  thej  are  in  this  instance)  projecting  beyond  the  mass  of 
heart  musculature  into  the  fat.  This  is  due  to  a  beginning 
regression  and  atrophy  of  heart  muscle,  leaving  the  vessels 
relatively  too  long.  The  septal  anastomoses  are  distinct  and 
abundant,  being  arranged  somewhat  in  the  fashion  of  a  row  of 
harp  strings.  In  the  cleared  specimen,  fat-vessels  are  quite 
well  developed  and  numerous. 

The  sixth  deeade  of  life  (Fig.  27)  shows  an  ever  increasing 
left-sided  vascular  preponderance  and  tortuosity  of  the  vessels. 
The  septum  shows  a  system  of  very  patent  and  free  arterial 
anastomoses.  The  increase  of  the  rami  tela-  adiposac  is  in  keep- 
ing with  the  other  changes. 

Figure  28  shows  verj  beautifully  the  stage  of  development 
of  these  four  features  in  the  seventh  decade  of  life;  the  increas- 
ing relative  anemia  of  the  right  side,  the  marked  tortuosity  oi 
the  vessels,  the  rich  and  abundant  septal  anastomoses  and,  in 
the  cleared  specimen,  the  well-developed   fat-vessel   network. 

In  the  eighth  decade  of  [ife  another  complicating  feature 
appears.  In  a  large  percentage  of  cases  arteriosclerotic  chang<  - 
are  seen.  This  is  well  shown  in  Figure  29.  Here  the  ramus  cir- 
cumllexus  dexter  presents  in  its  entire  extent  an  unevenness 
of  bore,  and  at  its  termination  just  before  the  ultimate  branch- 
ing, a  distinct  aneurysmal  bulging.  Moreover,  the  left-sided 
vascular  preponderance,  the  tortuosity,  the  rami  telae  adiposae 
and,  in  the  stereoscopic  plates  (for  this  plate  was  taken  at 
right   angles   with    the  direction   of  the  septum,    hence   shows 


138  THE  BLOOD  SUPPLY  TO  THE  HEART 

anastomoses  only  upon  stereoscopic  examination),  the  septal 
anastomoses  are  seen  to  be  distinctly  on  the  increase. 

Figure  30  is  a  composite,  representing  the  contrast  between 
the  circulation  of  the  heart  at  birth  and  in  the  seventh  decade 
of  life.  Here  one  sees  exceedingly  well  illustrated  the  difference 
in  the  relative  amounts  (if  blood  supplying  both  sides  of  the 
heart,  in  the  tortuosity  of  the  vessels  and  the  patency  of  the 
septal  anastomoses.  A  comparison  of  Plates  19,  2j  and  34 
shows  the  progressive  and  consistent  increase  of  the  rami  telae 
adiposae  from  birth  to  the  fourth,  and  from  this,  to  theeighth 
decade  of  life. 

Perhaps  there  is  no  better  way  of  concretely  establishing 
the  importance  of  these  changes  in  the  postnatal  evolution 
of  the  cardiac  vasculature  than  by  observing  their  effects 
upon  function. 

Figure  31  is  a  roentgenogram  of  a  heart  from  a  female,  aged 
seventy-three,  who  died  of  cancer  of  the  gall-bladder.  During 
life  she  had  no  symptoms  referable  to  the  heart  or  coronary 
vessels.  In  the  hospital  no  signs  were  found  during  life  indicat- 
ing a  lesion  of  the  heart.  Upon  injection  of  the  heart  at 
autopsy,  however,  it  was  seen  that  the  ramus  circumllexus 
dexter  presented  to  a  great  extent  of  its  course  an  arterio- 
sclerotic obliteration  which  was,  in  several  places,  almost 
complete.  The  myocardium  was  absolutely  intact,  no  suggestion 
of  an  infarct  being  present.  The  case  is,  in  short,  very 
similar  to  that  described  by  Galli.  A  more  careful  observation 
of  the  plate  shows  that  a  very  ample  and  abundant  anastomosis 
of  large,  patent  rami  interventriculares  supplied,  to  a  great 
extent,  the  right  side,  and  this  was  further  compensated  by 
an  extensive  labyrinthine  felt-work  of  rami  telae  adiposae 
which  massively  covered  the  right  ventricular  surface.  (Fig.  32 


Fie.   jo.     Roentgenogram  oi   th<    bl I  supply  in  the  average  In-art  at 

birth  and  in  the  seventh  decade,  illustrating  the  marked  evolutionary 
changes  which  the  advancing  age  periods  have  produced. 
i  59 


1 


Fig.    j  _       _  ted  heart,  showing 

well-marked   and  almost  complete  teration  of  the 


Fig.    ]i.  -Photograph    of   injected    and    cleared    specimen,    showing  the 
development  of  the  rami  telae  adiposae  on  the  right  side  of  the  heart, 

illustrated  in  Fig.  31. 


143 


Fig.   $3.     Microphotograph    of   a    section    through    the    arteriosclerotic 

vessel  from  the  heart,  illustrated  in  Iig.  31. 

145 


I  h,.    54.      Photograph  of  injected  and  cleared  specimen,  showing  the  rami 
telae  adiposae  on  the  left  side  of  the  heart,  illustrated  in  Fig.  31. 


14- 


AGE  PERIOD  CHANGES  IN  THE  BLOOD  SUPPLY    149 

shows  a  photograph  of  this  injected  and  cleared  specimen. )  I  hese 
fat-vessels  were  traced  into  the  musculature  and  were  found 
to  anastomose  with  persistent  right  branches  and  with  the 
compensating  left  ones. 

It  will  be  observed  in  the  roentgenogram  that  the  ramus 
os1  ii  ca\  at1  superioris  pursues  an  undisturbed  course  to  the  sino- 
auricular  nude  because  the  arteriosclerotic  process  commences 
i ust  beyond  the  origin  of  the  vessel  from  the  right  coronary 
artery. 

Figure  33  shows  a  microscopic  section  through  one  portion 
of  the  partialK  obliterated  artery.  It  is  seen  that  extensive 
obliterating  endarterial  changes  have  left  a  few  canalized 
areas  through  which  the  barium  (black  in  the  photograph)  has 
forced  its  way.  In  other  places  the  obliteration  was  even  more 
marked. 

The  conclusions  which  can  be  drawn  from  this  case  are, 
that  in  the  seventh  decade  of  life  the  vascular  architecture  of 
the  heart  is  well  prepared  to  receive  the  brunt  of  the  oblitera- 
tion even  of  a  main  coronary  artery,  not  only  on  account  of  the 
existence  of  abundant  and  free  anastomoses,  but  also,  as  is  seen 
in  this  cast,  by  the  non-negligible  factor  of  the  development 
at  this  age  period  of  a  dense  felt-work  of  arteriae  telae  adiposae 
which  can  compensate  and  supply  considerable  blood  to  the 
subjacent  muscle.  In  fact,  that  the  rami  telae  adiposae  are  able 
to  increase  in  caliber  and  quantitj  so  as  to  furnish  additional 
Mood,  is  seen  In  comparing  figure  52  with  Figure  34,  (which 
represents  the  posterior  surface  of  the  same  heart  and  shows 
a  fat-vessel  structure  commensurate  with  this  age  period). 
This  comparison  shows  that  the  increase  of  fat-vessels  on  the 
right  side  is  out  of  all  proportion  to  the  normal  development, 
but   it    must  be  remembered  that  this  great  increase  is  only 


i5o  THE  BLOOD  SUPPLY  TO  THE  HEART 

possible  on  a  basis  oi  an  already  well-developed  structure. 
Furthermore,  in  this  particular  case,  the  gradual  obliteration 
allowed  for  an  ample  development  of  these  compensating 
structures,  so  that  the  myocardium  was  left  absolutely 
intact. 

There  are  all  gradations  of  possibilities  which  lead  up  to 
this  interesting  case.  It  has  already  been  shown  in  Chapter  VI 
that  the  heart  possesses  in  the  anastomoses  a  structure  which 
can  and  does  give  the  heart  considerable  vascular  reserve.  This, 
moreover,  as  appears  from  our  present  discussion,  becomes 
gradually  more  and  more  valuable  for  such  a  purpose  as  age 
advances,  and  since  the  heart  presents  at  the  same  time 
a  parallel  increase  of  rami  telae  adiposae,  a  very  potent  ally,  it 
acquires  a  compensating  structure  whose  functional  possi- 
bilities increase  in  direct  proportion  with  age,  that  is,  with  that 
time  of  lite  when  pathological  processes  would  make  an 
increasing,  more  frequent  and  greater  demand  upon  it.  There 
is  thus  a  definite  functional  significance  in  these  progressive 
evolutionary  changes. 

That  the  rami  telae  adiposae  are  an  expression  of  a  general 
body  nutritional  reserve  structure  would  seem  to  be  indicated 
by  the  fact  that  they  have  been  found  by  the  author  in  other 
organs  which  show  a  senile  increase  ol  fat.  Thus,  for  example, 
in  the  senile  as  well  as  in  the  contracted  kidney,  the  very 
fatty  pelvic  contents  possess  a  rich  supply  of  arteriae  telae 
adiposae.  In  the  contracted  kidney,  they  can  distinctly  be  seen 
penetrating  the  pyramidal  parenchyma  and  supplying  it  with 
blood. 

It  appears  then,  that  there  is  a  definite  reason  tor  the 
progressive  increase  of  subpericardial  fat  as  shown  by  Figure 
1 6,  made  from  Midler's  figures,  and  that  this  serves  as  a  carrier 


AGE  PERIOD    CHANGES  IN  THE  BLOOD  SUPPLY    1,1 

lor  a  most  important  and  apparently  hitherto  unrecognized 
functional  and  compensating  unit. 

It  cannot  be  argued  that  the  development  of  fat-vessels  is 
entirely  secondary  to  functional  need,  lor  it  has  already  been 
shown  that  their  increase  is  progressive  and  proportional  to 
age,  irrespective  of  the  presence  of  a  pathological  lesion. 
It  is  true,  however,  that  an  obliteration  of  a  coronary  branch 
can  bring  about  an  added  development  and  quantitative 
as  well  as  qualitative  changes  in  them. 

The  increasing  tortuosity  of  the  vessels,  a  general  expres- 
sion of  increasing  age,  can  be  accounted  for  by  the  qualitative 
deterioration  in  the  vascular  wall  and  by  a  relative  shrinkage 
and  atrophy  of  the  heart  muscle  in  the  later  decades  of  life. 

There  remains,  therefore,  only  to  explain  the  gradually 
developing  relative  right-sided  anemia.  It  must  be  borne  in 
mind,  first  of  all,  that  this  is  to  a  great  extent  relative;  the 
increasing  Iclt-sidcd  musculature  and  consequently  vasculature 
overshadow  that  of  the  right  side.  Furthermore,  the  right 
ventricle  perhaps  does  not  so  much  present  a  regression  of 
\  essels  as  a  falling  behind  in  circulatory  development,  so  that 
it  becomes  relatively  more  and  more  anemic. 

\\  ithout  doubt,  these  changes  are  of  far-reaching  functional 
significance.  It  is  easy  to  comprehend  why  in  embryonic  life  the 
right  side,  which  is  the  more  acti\el\  functioning  one,  should 
attain  a  greater  development  of  its  vascular  tree.  This  persists 
for  some  time  after  birth,  but  with  the  assumption  of  greater 
acth  ity  b.\  the  left  ventricle,  the  latter  becomes  more  and  more 
richly  supplied  with  blood;  w  hereas  the  light  ventricle,  through 
less  acth  it  \  and  lesser  importance,  begins  to  lag  in  its  vascular 
development,  a  process  which  apparently  progresses  consist- 
cntk  throughout  lite. 


152  THE  BLOOD  SUPPLY  TO  THE  HEART 

As  old  age  approaches,  the  individual  is  ushered  into  an 
era  of  many  dangers  through  right-sided  heart  decline.  Thus, 
the  possibility  from  death  by  right-sided  heart  paralysis  in 
infectious  diseases  increases  with  age,  and  death  from  pneu- 
monia in  old  age,  so  frequent  that  it  is  practically  "physio- 
logical," comes  perhaps  somewhat  nearer  to  our  comprehension 
when  we  consider  that  this  lagging  right-sided  circulation, 
reacting  upon  the  right  ventricle,  produces  a  physiological 
right-sided  decline  or  increasing  heart  failure.  The  lung  tissue, 
which  depends  largely  upon  the  blood  from  the  pulmonary 
artery  for  its  nutrition,  receives  an  increasingly  sluggish 
supply  and  becomes,  therefore,  a  more  and  more  suitable 
soil  for  a  terminal  infection.  (Oertel  states  that  in  a  long 
autopsy  experience  of  almshouse  cases,  many  of  which  con- 
cerned, of  course,  senile  decrepits,  it  was  not  infrequent  to 
discover  unsuspected  pneumonias  in  sudden  deaths;  for 
example,  in  individuals  who  had  retired  at  night  in  apparent 
relative  health  and  were  found  dead  next  morning.  This  has 
also  a  certain  medicolegal  interest.) 

Perhaps  it  is,  therefore,  permissible  to  paraphrase  in 
this  connection  the  old  adage  about  a  man  being  as  old  as  his 
arteries,  so  as  to  read,  "A  man  is  as  old  as  his  Right  Coronary 
Artery-" 


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Tedischi.     I  In  1   die  Fragmentation  des  Myocardium.     Vircbow's  Arcb., 

Berl.,   1S112,  (  \\\  in. 
Thebesils.     Dissertatio  de  circulo  sanguinis  in  corde,  Lugdunum  Batav- 

orum,  i~o8. 
Theile.     Traite  myologie  et  d'angeiologie,  Paris,  1843,  xvi. 
I  in  [lhaber.     Munchen.  med.  Wcbnscbr.,  June  4,  mi-. 
Imihiii.       11   V'orlauligc   Mitteilungen   iiber  eine  besondere   Muskelver- 

bindung  zwischen   der  Cava   superior   und  dem   Hisschen    Biindel. 

Munchen.  med.  Wcbnscbr.,  Ivi,  No.  42. 
(2)  Ueber  den  Aufbau  des  Sinusknotens  unci  seine  Verbindung  mit  der 

Cava  superior  und  dvn  Wenckebachschen  Biindeln.    Munchen.  med. 

Wcbnscbr.,  1910,  No.  4. 


1 64  BIBLIOGRAPHY 

Trendelenburg  and  Cohn.     Zur  Physiologie  des  Ubergangbiindels  am 

Saugetierherzen.    Centralbl.  J.   Physiol.,   Leipz.    u.  Berl.,    1900,   xxiii. 
Valentin.     Uber  die  gegenseitigen  Massenverhaltnisse  der  rechten  und 

der  Iinken  Rammer  des  Herzens.  Ztschr.  j.  rationelle  Medizin,  Zurich, 

1844,  1,  8. 
Verheven.     Anatomiae  corporis  humani  liber  primus,  Coloniae,   i~i2. 
Vesalius.     De  humani  corporis  fabrica  Iibri  septem,  2d  ed.,  Basileae,  1555. 
Vieussens.     (1)  Nouvelle  decouvertes  sur  Ic  coeur,  Toulouse,  1706. 
(2)  Traite  nouveau  de  la  structure  et  des  causes  du  mouvement   naturel 

du  coeur,  Toulouse,  1-15. 
Waugh.     Studies  on  the  Bone-marrow  in  Disease,  McGill  Medical  Society, 

Senior  Prize  Essay,  1920. 
Weed.     Johns  Hopkins  Hosp.  Bull.,  October,  1920,  xxxi. 
Wenckebach,     (i)  Beitrage  zur  Kentniss  der  menschlichen  Herztatigkeit. 

Arch.  j.  Anal.  u.  Phys.  (Phys.  Abteil.),  Leipz.,   1906  and  1907. 

(2)  Arch.  J.  Physiol.,    Leipz.,   190",  xx. 

(3)  Arch.  d.  mal.  du  coeur  etc.,  Par.,  1908,  No.  2. 
\\  heeler.     Slow  pulse.  Brit.  M.  J.,  1880,  i. 

Wilson.     Nerves   of  the   atrioventricular  bundle.    Anat.    Record,   April, 

1909. 
Winslow.     Exposition    anatomique   de   la   structure   du   corps   humain, 

Paris,  1776. 
Wissiliewski.     Zur   Frage  uber  den   Einfluss  der  Embolie  der  Koron- 

ararterien  auf  die  Herztatigkeit  und  den  Blutdruck.  Ztschr.  j.  e.xper. 

Path.  u.  Therap.,  Berk,  191 1,  ix. 
Woolley.     Three  cases  which   illustrate  the  consequences  of  coronary 

lesions.  J.  Lab.  &  Clin.  M.,   1917,  iii,  18. 
Wybauw.     Existe-t-il  des  vaisseaux  sanguins  dans  les  valvules  du  coeur? 

Arch.  d.  mal.  du  coeur,  etc.,  Par.,  1918,  xi. 
Zimmerl.     Ricerche  anatomo-comparate  sui  vasi  cardiaci  degli  animali 

domestici,  Parma,  1900. 


INDEX  OF  PERSONAL  NAMES 


Abbott,  Maude  E.,  -2 
Amcnomiya,  23,  83,  90 
Anderson,  106 
Ashcroft,  39,  81,  84 

Banchi,  80 

Bayne-Jones,  9,  55,  56,  58 
Bcncke,  109 
Bi  1  mil,  79 
Bettelheim,  80 
von  Bezold,  79 
Bickell,  80,  84 
Bizot,  109 
Black,  M.,  \l 
Bochdakk,   50,   [00 
Bochefontaine,  80 
Boll,  105 

Branch,  xi 
Breymann,  79 

liriicki  ,  29 

Cadiat,  i4 

Caldani,  -i>,  84 
Cheney.  II.  II..  8 
Chiari,  84 
Chirac,  78 
( !oen,  54 

Cohnhcim,  Ho,  82,  89 
(  loplin,  niii 
Councilman,  1 12 
Cruveilhier,  30,  79,  94,  99,  1 
Curran,  40 


Darier,  54 
Dock,  81 ,  84 
DngicI,  3.1 

I        eff,  80 
Droguell,  So,  82,  84 
Dutto,  2 

Einthoven,  1 1 2 
Engel,  109 
Engelhardt,  84 
Fngelmann,  30 

1  n,  -i) 
I  il  mger,  31) 


;6,  57,  67 


I    In',  39 
Fallopius,  1,  30 
Fantoni,  29 
Fenoglio,  80,  82,  84 

Flack,  39,  40,  41 
Forstcr,  54 
Frey,  54 

von  Frey,  80,  84 
1  u,  2,  81 

Fujinami,  82,  89 

Galli,  81.  84,  on,  138 
Gaskell,  31; 
Gerlach,  ^4 
Glew,  2 

Gross,  \  ii 

Haas,  Georg,  41,  42,  46,  47,  52 
Holier,  1,  -8,  84,  100 
I  [ansemann,  105 

1  laucll,  3 

I  [enle,  54.  79,  ioo 

Ikring,  39 

Herrick,  81,  83,  84,  91 

I  [erxheimer,  106 

I  leu  son,  3 

I  [ildebrand,  2 

I  [irsch,  S2,  89,  90 

I  lis,  W.  Jr.,  39 

Howell,  75 

Huber,  81,84 

Huchard,  84 

I  [yrtl,  1,  2(j,  30,  -9,  mo 

Jamin,  2,  81,  84 
Jenner,  79 

Joseph,  54 

Keith,  30,  40,   1 1 
Kent,  39 

Koch,  31),  40,  4.;,  46 
Kollikcr,  ,-4 
Kolster,  80,  84 
KSnigi 

Koster,  19,  i  j 
Krause,  79 
165 


1 66 


INDEX  OF  PERSONAL  NAMES 


Krehl,  81,  84 
Kronecker,  80 
Kiirschner,  57 

Lancisius,  100 

Langer,  54,  55,  57,  67,  79,  89,  100,   10 1 

Lannelonguc,  101 

Le  Cat,  102 

Lewis,  112,  113 

Lexer,  2,  108 

Lusclika,  54,  56,  100 

Manzone,  57 

Marshall,  94,  102 

Matthews,  82,  84 

McCordick,  10 

McWilliams,  80,  84 

Meigs,  19 

Merkel,  2,  81,  84 

Miller,  2,  82,  84 

Minot,  105 

Moenckeberg,  39,  41,  49,  50,  52 

Morgagni,  29,  30,  78,  84 

Morgan,  J.  D.,  xi,  7 

Miiller,  106,  1  io,  150 


Notkin,  M.,  71 
Nussb;ium,  1,  23,  55, 


3,  83,  84,  1 01 


Odinzow,  55,  57,  58 

Oertel,  Horst,  xi,  105,  106,  107,  152 

Opitz,  2 

Oppenheimer,  90 

Osier,  75,  81,  84 

Pagenstecher,  84 
Panum,  79 
Parry,  79 
Piquard,  29,  103 
Pitts,  xi 

Porter,  80,  82,  84,  94 
Pratt,  89 
Purkinje,  39 

von  Recklinghausen,  82,  89 
Reid,  94,  106 
Reitmann,  106,  107 


Ribbert,  19,  74 
Riolanus,  1,  30 
Rokitansky,  54 
Rosenstein,  54 
Rothschild,  90,  91 
Roussy,  80 
Roux,  105 
Riihle,  53 

Samuelson,  79,  81,  84 

Sand,  Rene,  107 

Sappey,  54 

von  Schulthcss-Rechberg,  A.,  80 

See,  G.,  80 

Seniple,  xi 

de  Senac,  78,  84,  100 

Siding,  102 

Skinner,  2 

Smith,  3,  83,  84,  90 

Spalteholz,  4,  41,  81,  82,  84,  90 

Stegmann,  3 

Sternberg,  33 

Tandler,  29,  30,  40,  37,  94,  101,  102,  104 

Tawara,  39,  41,  81,  84 

Thebesius,  78,  83,  84,  100,  10 1 

Theile,  100 

Theilhaber,  106 

Thorel,  39,  84 

Tigerstedt,  80,  84 

Valentin,  109 
de  Vecchi,  74 
Vesalius,  1 
Verheyen,  100 
Vieussens,  100 
Virchou ,  S4 

Waugh,  \,  in- 
Webster,  H.  E.,  xi 
Weed,  107 
West,  84 
Winslow,  94,  100 

Zimmerl,  80 
Zinn,  IOO 
Zuckerkandl,  99,  100 


SUBJECT  INDEX 


Acute  endocarditis  and  congenital  cardiac 

defects,  72,  73 
Age  period  changes  in  blood  supply,  105 
152 

anastomoses,  Functional  value  in 

age,  150 
anemia,  right-sided,  relative,  151 
average  heart  of  first  decade,  113 

-  second  decade,  1 14 

-  third  decade,  1 14 

-  fourth  decade,   1  14 
fifth  decade,  137 
sivtll  decade,    I  3- 

—  seventh  decade,  1 37 

-  eighth  decade,   1  3- 

—  bone-marrow,      conclusions      of 

Waugh,  107 

—  compensating  anastomoses,  138 

—  contrast    cj|    heart    a1    birth    and 

seventh  decade,  1 3S 
<  loplin        finds      instabilit  \        oi 

thymus,   106 
degeneration,      senescence      and 

new    grow  tli.    i"i 

ductless  glands  unstable,  m<> 
emlji  yo  development,  tog 
fat-vessels   increase   proportional 

to  age,   151 

heart   hypertrophy  in  age,  1 12 
hyaline  glomeruli   in   kidneys  ol 

children,    1  of  > 
injected    specimen    oi    heart    at 

birth,   1  13 
mass  of  right  and  kit  ventricles, 

table   of,    I  I  I 

MUller's  studies  and  conclusions, 
1  10 

Muller's  weight  ind  measure- 
ments of  the  heart,    [on 

Oertel's  si ml\  1 1!  pancreas,  107 

pia  arachnoid,  structural  modi- 
fications in,  10- 

postnatal  evolution  of  the  spleen, 


1  \  oiutions, 

sinus,    10S 


( lertel's     ci  m<  lu 


167 


Age   period   changes,  postnatal,  heart  de- 
velopment, 1 1 3 

—  rami      telae     adiposae     part     ol 

nutritional     reserve    structure, 
I  -;o 

—  Reid's      measurements       ol       the 

heart,   106 
Reitmann  s  studs  ol  the  pancreas, 

106 
right-sided   heart   decline   in   age, 
1,-2 

seventh    decade,    rami    telae  adi- 
posae, increase  in  calibei 
in,  140 
-vascular     architecture     in, 
■49 
spleen,    [07 

subpci  icaulial      and      subeni  tne 

ous  fat,    [10 

—  Theilhaber    finds    instability     in 

the  endometrium,  106 

tortuosity    ol    vessels    accounted 

for,  151 
turning  point  in  heart  growth,  110 
Anastomoses      between      the      coronary 
ait  cries,  77-92 
anesthetics,  correct  choice  ol  in  experi- 
ments, S2 

—  arteriae  telae  adiposis  cordis,  85 
-auricular  and  ventricular  walls  seat    ol 

e\tensi\  e,  85 

branches  ol  each  arterj  anastomosed,  89 

(    aids  in'-    dissect  ioiis,   -i) 

—  capillar)  anastomosis  numerous,  85 
—  chrome-yellow  injections,  si 
-clamping     experiments    of   Cohnheim 

and  von  Schulthess-Rechberg,  Mo 
-  conclusions  as  to  existence  of,  89 

COronarj  arteries  and  adjacent  vessels 
anastomosed.  So 

earliest  historical  experiment  .  78 

I  1  a  risen'  experimental  ligatures  ol 
coronaries,  79 

I  act  01s  ,  mployed  In  various  investiga- 
tors, 77 

functional  end-arteries,  89 


1 68 


SUBJECT  INDEX 


Anastomoses,  Haller's   conclusions   based 
on  dissection,  78 

—  heart  the  richest  organ  in,  84 

—  Herrick's  clinical  classification 
of  angina  pectoris,  83 

—  Hirsch's  tying-off  experiments,  82 

—  HyrtI  denies  existence  of,  79 

—  in  heart  universal,  89 

—  infarcts,  Amenomiya's  conclusions,  90 

—  and  compensation,  91 

—  formation  of,  1S9 

—  Hirsch's  conclusions,  90 

—  interventricular  septum  seat  of  exten- 

sive, 85 

—  investigations  of  Thebesius,  78 

—  Langer's  comprehensive  findings,  79 

—  ligation  experiments  in  dogs,  80 

—  Nussbaum    finds    connection    between 

arteries  and  veins,  83 
obliteration     ol     coronary     branches, 
results  of,  Si 

—  Parry  and  Jenner's  findings,  79 

—  radiographing  red  lead  injected  arteries, 

81 
■ — right    and    left    arteries    anastomosed, 
89 

—  small  vessels,  complete,  85 

—  Smith's  conclusions   from   experiments 

on  dogs,  83 

—  Spalteholz's  conclusions,  82 

—  vessels     in     the    parietal    pericardium, 

89 
Aortic  valve,  vasculature  in,  68 
Arteria  circumflexa  dextra,  12 
Arteriae  telae  adiposae  cordis,  22 
Auricular  branches  of  coronary  arteries,  20 

Barium  sulphate  gelatine,  8 

injections,  4 

Bayne-Jones'  method  with  gelatine,  9 
Bibliography,  1  -53-164 

Blood  supply  to  heart  as  a  whole,  23-25 

—  to  ventricles  and  auricles,   11-25 
Blood-vessels  in  valves,  53 
Bone-marrow,  changes  in,   101 

Carmine  gelatine,  9 

Chrome-yellow     injections     of    coronary 

arteries,  81 
Clamping  corona  r\   arteries  of  dogs,  80 
<  Oronarj    arteries,    anastomoses   between, 
—   92 


Coronarv   arteries,  arteria   coronaria   dex- 
tra, auricular  supply,  33 

ventricular  supply,  31 

arteria   coronaria   sinistra,  auricular 

supply,  36 
—  ventricular  supply,  34 

—  auricular  branch,  first,  20 

second  anterior,  2 1 

branches,  course  of,  20 

—  blood  supply  from  single,  30 

branching  variations  and  functional 

differences,  37 

—  demarcation     between     supply     of 

right  and  left,  23 
Haller's  account  of,  1 

—  Hyrtl's  method  of  injecting,  1 
lateral  branch,  22 

—  left,  anatomy  of,  15 
beginning  of,  1  5 

percentage  of  circulation  from,  3-r 

rami  marginales,  1 5 

ramus  circumflexus  sinister,  16 

ramus  deseendens  anterior  sinis- 
ter, 15 

—  second  main  division,  15 

—  multiple  origin  of,  30 

—  rami  descendentes,  19 

rami  scpti  fibrosa,  course  of,  20 

ramus  ostii  cavae  superioris,  role  of, 

37 
—  ramus  circumflexus  dexter,  termina- 
tion ot,  31 

— sinister  termination  ol,  34 

ramus  deseendens  anterior,  termina- 
tion of,  34 
right,  anatomy  of,  12 

—  first  ventricular  branch,  12 
percentage  of  circulation  from,  36 

ramus  deseendens  posterior,    1  5 

terminal  portion,  15 

—  site  of  origin,  29 

—  statistical  analysis  of  variations  in 

distribution,  29 

—  typical  variation  in  distribution  of, 

26 
variation,  first  characteristic,  35 

in  distribution  of,  26-  38 

in  main  branches,  31-38 

most  frequent  seat  ol,   37 

Darier,    conclusions    of   as    to    vessels    in 
valves,  5  t,  55 


SUBJECT  INDEX 


16  9 


Dilatation     through     use    of    potassium 
sulphocyanide,  io 

Distribution  of  coronary  arteries,  typical 

lions  in,  26 
Ductless  glands,  instability  of,  to6 

!    11I. 1    1   ob  ervations  on  blood  supply,   1 
I  mbryo,  ventricles  in  the,  109 
Embryogenesis  of  heart  veins,  93 
I  rditis,  Abbott's  studj  on  incidence 

ute,  72 

—  of  bacteria,  -4 

relation    to    musculature    and    blood- 
vessels in  valves,  58,  67 

—  typical  injection  in,  67 

—  valvular  blood-vessels  as  cause  of,  75 
Endometrium,  instability  of,  [06 
Experimental   ligatures   of  coronaries   in 

animals,  79 

I   it  as  nutritional  reserve,  ijo 

—  brandies,  22 

—  proportion  between  subpericardial  and 
subcutaneous,   110 

Fat-vessels  and  functional  need,  151 

I   ital    results    in   animals   from   selecting 

wrong  anesthetic,  82 
Functional  end-arteries,  Pratt's  definition, 


Gelatine,  barium  sulphate,  8 

—  carmini  ,  9 

—  pigmented,  injections  of,  ; 

- —  Prussian-film  ,  9 

\periments  and  conclusions,  42 
anastomoses     as     protection    at 
t  li  decade,   140,    1  JO 
led,  1  •;  1 
lv<  rage,  in  Brs1  decade,  1 1 3 
in  second  decade,  1  14 

—  in  third  decade,   1  14 

—  in  fourth  decade,   1  14 
—  in  fifth  decade,   [  5- 

in  sixtll  decade,    I  5- 

in  seventh  decadi  .   1  | 

in  eighth  decade,  1  i~ 

1S1    in  i  in  illation  of,  at  birth  and 
seventh  decide,   1  j8 

—  embryonic  right-sided  development,  15 1 

li  it-sided  development,  151 


Heart,  postnatal  evolution  and  effects  on 
function,  138 

—  right-sided  decline  in  age,  152 

—  tortuosity  of  vessels,  increasing,  151 

—  valves,     frequency     and     duration    of 

compression  of,  75 

influence    of    age     on      inatomii  J 

changes,  75 
1 111  rick's  clinical  classification  oi 

pei  toris,  83 
I  li-.  bundle,  histology,  40 
II,  ilmc  glomeruli  in  kidneys  ol  children, 
[06 

Infucts,    age    of    individual    as   affecting 
formation  of,  90 

—  Amcnomiva's  conclusions,  90 

—  factors  in  determining,  92 

—  Hirsch's  conclusions,  90 

—  situation  of,  90 

—  variability  of  occurrence,  90 

Kfister's    theory  of  embolic  endoc 
S3 

Left  coronarj   artery,  anatomy  of,   li 

—  limb  ol  neuromuscular  structure  source 

of  nourishment,  4.7 
Ligation  experiments  on  dogs,  80 

Measurements  of  the  heart,  106 
Metal  injections  in  coronarj  artery,  1.  2 
Multiple  origin  of  corollaries,    50 
Neuromuscular   tissue,   blood    supply    to, 

39"52 

auriculoventricular    node,     po  itiori 

of,  [9 

auriculoventricular      node,       special 

blood  supplj  ,  41 
author's  findings  differ  from  Koch's, 

45 

bundle,  fat  and  pigment  in,    \'i 

■ specificity  of  blood  supply  to,  50, 

Haas'  experiments  and  conclu 

42 

His  bundle,  histology  of,  40 

left  limb  ol  neuromuscular  structure, 

4" 
ramus  0  lerioris,  45 

ramus  septi  fibrosi,  origin  and  course 

of,  46,  48 


170 


SUBJECT  INDEX 


Neuromuscular  tissue,  right  limb  of  neuro- 
muscular bundle,  course  of,  47 

—  scarring  of  bundle,  50,  51 

—  sino-auricular  node,  position  of,  39 

vascular  system,  40 

—  structure,  description  of,  39 

—  vascular      variations      alter      blood 

supply,  48 
Normal  valves,  conflicting  opinions  as  to 
vessels  in,  53 

Obliteration    of   coronary    artery,    age  of 
individual  as  affecting,  90 

compensation  in,  91 

effects  of,  5 1 

—  varying  results  of,  81 

—  coronary  branches,  results  of,  81 

Pancreas  an  unstable  organ,   106,   107 
Papillary  distributions,  19 

—  muscles,  19 

Parietal  pericardium,  connections  between 
vessels  of  and  coronary  arteries,  89 

Pars  membranacea  septi,  20 

Pathological  lesions  due  to  interrupted 
blood  supply,  49 

Pericardium,  anastomoses  between  coro- 
nary arteries  and  those  of,  80 

Pia  arachnoid,  structural  modifications  in, 
107 

Postnatal  evolution,  Oertel's  conclusions, 
108 

Potassium  sulphocyanide  for  dilatation,  10 

Prussian-blue  gelatine,  9 

Purkinje  fibers,  distribution  of,  49 

Radiography   in   study   of  vascular  struc- 
ture, 2,  4 
Rami  anteriores,  20 

—  interventriculares,  19 

—  marginales,  15 

—  ventriculares  sinistri,  15 
Ramus  circumflexus  sinister,  16 

—  descendens  anterior  sinister,   15 

—  posterior,  15 

—  lateralis,  12 

—  ostii  cavae  superioris,  21,  33 

—  septi  fibrosa,  20,  48 

Red  lead  injections  of  coronary  arteries,  81 
Right  and  left  ventricles,  comparison  of 
mass  ol,  1 1 1 

—  coronary  artery,  anatomy  of,  12 


Right     limb    of     neuromuscular     bundle, 

course  of,  47 
—  ventricle  veins  draining  anterior  surface 

of,  98 
Ruble's  theory  of  endocarditis,  53 

Serial  sections,  unreliability  ol,  42 
Site  of  origin  of  coronary  arteries,  29 
Smith's  studies  ol  anastomoses  in  dogs,  83 
Spleen,  changes  in,  107 
Statistical  analysis  of  variations  in  distri- 
bution of  coronary  arteries,  29 
Sulcus  terminalis,  21 

Technique  employed  in  these  studies,  1-10 
Theoretical  heart  capillary  distributions,  19 

deeper  divisions,  16-22 

papillary  muscles,  19 

representing  average  specimen,  1 1 

—  superficial  divisions,  11-16 
Thymus,  instability  of,  106 
Tying-off  experiments  on  dogs,  82 

Valve  musculature  decreases  with  age,  57 
Valves,  blood  supply  to,  53-76 

—  aortic  valve,  vasculature  in,  68 

—  bacteria     as     factors     in     endo- 

carditis, 76 

—  Bayne-Jones'  findings,  55,  56 

—  blood-vessels  and  musculature,  57 

—  conflicting  opinions  as  to  blood- 

vessels, 53 

—  coordination  of  conflicting  views, 

57 

—  Darier's  conclusions  as  to  vessels 

in  valves,  54,  55 

—  duration  of  valve  compression,  75 

—  endocarditis,  author's  findings  in, 

67 

—  endocarditis,    relation    to    blood 

vessels  and  musculature,  -;S,  6" 
— endocarditis,     typical    injections 
in,  67 

—  essential    to    theory    of    embolic 

endocarditis,  56 

fetal  valves,  musculature,  71 

fetal  valvular  endocarditis,  -i 

—  infantile  valvular endocardit  i--.  7  1 

—  Luschka  on  vascularization,  54 
mitral  valve,  aortic  cusp,  71 

—  musculature  decreases  with  age, 

57 


SUBJECT  INDEX 


171 


Valves,    blood    supply    t<>,   normal    heart 

rarely  shows  vasculature,  72 
■ — parallelism  of  congenital  anoma- 
lies and  endocarditis,  72,  73 
—  regression    of    blood-vessels    and 
musculature,  58 

—  of  musculature,  71 

Riihle's   theory   of  endocarditis, 

53 
valvular  endocarditis  in  adults,  71 

—  endocarditis,  relation  of  blood 

vessels  to,  74 
— vasculature  in  valvular  endocar- 
ditis, 72 
Variation  in  main  branches  of  coronary 

arteries,  31  -38 

—  veins  of  the  heart,  102 

Vascular  variations  alter  blood  supply,  48 
Veins  of  the  heart,  03-104 
foramina  Thebesii,  100 
divisions  of,  101 

—  in  embryonic  life,  102 


Veins,  of  tin  heart,  methods  of  injecting,  to 

sinus  coronarius,  93 

truncus  communis,  103 

■ variations  in,  102 

vena  coronaria  cordis  sinistra,  04 

dextra,  97 

sinistra,  93 

vena  Galeni,  103 

vena   mterventricularis  anterior,  94 

vena    interventricularis  poste- 
rior, 97 

vena  marginis  acuti,  97 

vena    obliqua    atrii    sinistri     (\Iar- 

shalli),  97 
—  venae  magnae  cordis,  93 

venae  mintmae  Thebesii,  100 

venae  parvae  cordis,  99 

venae  ventriculi  dextri,  98 

—  sinistri,  97 
Venae  Thebesii,  too 

Wax  medium  of  Lexer  and  Hildebrand,  2 


Paul  B.  Hoeber 

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